Recognizing and Reporting Abuse, Neglect and Exploitation

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.

Hospice patients are among the most vulnerable people in Georgia: often bedbound, confused, unable to speak, and dependent on others for medication and care. Controlled medications in the home create a particular risk of exploitation and diversion. This policy makes sure that everyone at Sample Agency, LLC (the "Agency") recognizes abuse, neglect and exploitation and reports it at once to every body Georgia law requires, and that the patient is protected while that happens. Every patient has the right to receive hospice care in a manner that neither physically nor emotionally abuses the patient, nor neglects the patient’s needs (Ga. Comp. R. & Regs. 111-8-37-.10(1)(d)).

Any act or failure to act, by anyone, that harms or could harm a patient: Agency employees, contractors and volunteers; family members, caregivers, friends and household members; staff of a nursing home, personal care home, assisted living community or inpatient facility; other residents and visitors; and strangers. It applies at home, in facilities and in any hospice care facility the Agency operates, and to patients of every age.

The following terms have the meanings given below when used in this policy.

Every Agency employee who provides or supports patient care is a mandated reporter. O.C.G.A. §30-5-4(a)(1)(A) requires these persons, among others, to report when they have reasonable cause to believe that a disabled adult or elder person has been the victim of abuse, other than by accidental means, or has been neglected or exploited: any person required to report child abuse under O.C.G.A. §19-7-5(c), which includes physicians, physician assistants, hospital or medical personnel, registered and licensed practical nurses, nurse’s aides, licensed professional counselors and social workers; physical therapists; occupational therapists; employees of a public or private agency engaged in professional health related services to elder persons or disabled adults; and clergy members. The Agency requires every employee, contractor and volunteer to report, whether or not the statute names that person’s role.

Where hospice staff have reasonable cause to believe that a disabled adult or elder person has been the victim of abuse, other than by accidental means, or has been neglected or exploited, the Agency reports to an adult protection agency providing protective services as designated by the Department and to an appropriate law enforcement agency or prosecuting attorney (Ga. Comp. R. & Regs. 111-8-37-.06(2); O.C.G.A. §30-5-4(b)(1)(A)). Separately, any rape, assault, or any abuse, neglect or exploitation of a patient is reported to the Department within 24 hours or the next business day (Rule 111-8-37-.06(1)(b); Policy GA-HSP-QA-02).

The Georgia statute sets no number of hours for the adult protective services report. The Agency’s own standard is that the report is made immediately, and never later than the end of the shift or visit in which the staff member formed the belief. A report is made even where the information came from a communication that is otherwise privileged or confidential, except that a member of the clergy is not required to report matters confided solely within the context of confession or similar communication required to be kept confidential under church doctrine or practice (O.C.G.A. §30-5-4(d)). A person who makes a report in good faith is immune from civil liability and criminal prosecution on account of the report (O.C.G.A. §30-5-4(c)), and failure to make a required report is a misdemeanor (O.C.G.A. §30-5-8).

If the Agency is Medicare-certified, every hospice employee and contracted staff member reports every alleged violation, including injuries of unknown source and misappropriation of patient property, by anyone furnishing services on behalf of the hospice, immediately to the hospice administrator (42 CFR §418.52(b)(4)(i)). The Agency applies this as its own standard to every concern, whoever the suspected person is.

Hospice patients often have bruising, skin breakdown, weight loss, confusion and falls because of their illness. Staff do not dismiss a sign because it could be disease-related; they report what they see and hear and let the investigators decide. Watch for:

• Physical: unexplained bruises, burns, fractures or marks in the shape of fingers or objects; injuries at different stages of healing; a patient who flinches or is afraid of a caregiver; restraint marks.
• Sexual: injury, bleeding or infection in the genital area; a patient’s report or sudden fear of a particular person.
• Emotional: threats, insults, isolation from friends or the hospice team, a caregiver who will not let the patient speak alone with staff.
• Neglect: a patient left soiled, hungry, thirsty or alone; untreated pressure injuries; medications or oxygen not given; a caregiver who refuses the care the plan of care needs; in a facility, care in the plan not being given by facility staff.
• Exploitation and diversion: missing money, valuables or bank cards; sudden changes to a will, deed, power of attorney or bank account; pain medications that run out early or counts that do not match; a caregiver asking for more opioids than the patient seems to use.
• Unreasonable confinement: a patient locked in a room, tied, or kept from leaving or from seeing visitors.

Table 1 shows the reports each situation needs. More than one row may apply; make every report that applies. In every case, also tell the Administrator at once (Section 7, step 2).

Each report includes, as far as known: the name and address of the patient, and should include the name and address of the caretaker, the patient’s age, the nature and extent of the injury or condition, and other pertinent information (O.C.G.A. §30-5-4(b)(2)); for a facility resident, also the name and address of the facility, the suspected cause and the reporter’s own name and address (O.C.G.A. §31-8-82(d)). Report even if some details are unknown.

1. Protect the patient (any staff member, at once). Make the patient safe; call 911 if needed. Do not leave the patient alone with a suspected perpetrator. Do not confront the suspected person or disturb evidence. If controlled medications may be diverted, follow Policy GA-HSP-MED-02 to secure or count them.
2. Tell the Administrator (any staff member, at once). Call Pat Sample on (404) 555-0100, or the Alternate Administrator, Jo Sample, or the on-call line (404) 555-0199. Give the patient’s name, what you saw or heard, when, and who was involved. This internal report never replaces the external reports.
3. Make the external reports (Administrator, with the staff member). Use Table 1. The Administrator or Alternate Administrator makes the reports with the staff member on the line or present, so that the person with first-hand knowledge gives the facts. If neither can be reached within one hour, or the shift is ending, the staff member makes every report personally. Anyone may report directly at any time without asking permission.
4. Record the report. Write down the date and time of each call or online submission, the intake worker’s name, the law enforcement agency and officer, and any intake or case number, and give them to the Administrator for the incident file. Complete Form GA-HSP-QA-01-A.
5. Report to the Department. The quality lead or Administrator makes the incident report to the Department within 24 hours or the next business day (Policy GA-HSP-QA-02).
6. Remove the alleged perpetrator. If an Agency employee, contractor or volunteer is alleged, the Administrator removes that person from all patient contact pending the investigation (Policy GA-HSP-ANE-02).
7. Start the investigation. The Administrator starts the internal investigation immediately under Policy GA-HSP-ANE-02.
8. Inform the patient. Unless doing so would place the patient at risk of serious harm, or the person who would be told is believed to be responsible for the abuse, the Administrator informs the patient or representative that a report was made (45 CFR §164.512(c)(2)).
9. Update the plan of care. The hospice care team reviews the patient’s safety, caregiver arrangements and medication management, and documents the facts and the care given in the medical record without opinions and without mentioning the incident report.

When a staff member who must report child abuse attends to a child as part of his or her duties for the Agency, the staff member may notify the person in charge (the Administrator or Alternate Administrator), who must then report or cause a report to be made; the staff member who notifies the person in charge is deemed to have complied (O.C.G.A. §19-7-5(c)(2)). The person in charge may not control, restrain or modify the information provided by the reporter, or make any other change to it (O.C.G.A. §19-7-5(c)(2)). The report is made immediately, but in no case later than 24 hours from the time there is reasonable cause to believe that suspected child abuse has occurred (O.C.G.A. §19-7-5(e)(2)). As the Agency’s own standard, if the person in charge has not confirmed within one hour that the report was made, the staff member reports directly to 1-855-422-4453 (1-855-GACHILD).

• At admission each patient and, where applicable, the patient representative receives Form GA-HSP-ANE-01-A, which explains the patient’s right to be free from abuse and neglect and how to report directly to Adult Protective Services, the Department, the Division of Family and Children Services and the Agency. The patient’s signed acknowledgment is filed in the medical record. The form is available in Spanish and is explained in a language the patient understands.
• Orientation for every person providing services includes patient rights including abuse reporting requirements, and the Agency’s policies on reporting abuse and neglect (Ga. Comp. R. & Regs. 111-8-37-.13(2)(b)-(c)). The annual training for all staff and volunteers who provide hands-on care includes recognizing abuse and neglect and reporting requirements (Rule 111-8-37-.13(4)(b)).

No person shall discriminate or retaliate in any manner against any person who makes a report, testifies, provides protective services or participates in an investigation, or against any disabled adult or elder person who is the subject of a report (O.C.G.A. §30-5-4.1). The Agency does not reduce or end a patient’s services because a report was made. If the Agency is Medicare-certified, patients have the right not to be subjected to discrimination or reprisal for exercising their rights (42 CFR §418.52(b)(1)(iv)). Any employee who discourages, delays or retaliates for a report is disciplined.

Each role named below carries the duties shown.

The Administrator keeps a confidential incident file for every concern reported, with the internal report, Form GA-HSP-QA-01-A, the date and time of each external report and the intake or case number, the Department incident report, protective actions, and the link to the investigation file (Policy GA-HSP-ANE-02), for at least six years (the Agency’s own standard). Acknowledgments of Form GA-HSP-ANE-01-A are kept in the medical record. Each quarter the quality management committee reviews the number and type of reports and the time from awareness to each report, and the Administrator checks a sample of new admissions for the signed acknowledgment (Policy GA-HSP-QA-01).

Every employee, contractor and volunteer is trained at orientation, before any patient contact, on Sections 4 to 9, with practice scenarios for home and facility settings, and annually thereafter (Ga. Comp. R. & Regs. 111-8-37-.13(2), (4)(b)). Managers and on-call nurses are also trained on making each report in Table 1. Training is recorded under Policy GA-HSP-HR-01.

This policy implements the following authorities.

• O.C.G.A. §30-5-3, definitions
• O.C.G.A. §30-5-4, reporting of need for protective services
• O.C.G.A. §30-5-4.1, no retaliation
• O.C.G.A. §30-5-8, failure to report
• O.C.G.A. §§31-8-81 and 31-8-82, abuse of long-term care facility residents
• O.C.G.A. §19-7-5, reporting of child abuse
• Ga. Comp. R. & Regs. 111-8-37-.06(1)(b), (2), reports to the Department and to the adult protection agency
• Ga. Comp. R. & Regs. 111-8-37-.10(1)(d), right to care free of abuse and neglect
• Ga. Comp. R. & Regs. 111-8-37-.13(2), (4)(b), orientation and annual training
• 42 CFR §418.52(b)(4), (c)(6), reporting alleged violations; right to be free from abuse (Medicare-certified hospices)
• 42 CFR §418.112(c)(8), alleged violations in SNF/NF or ICF/IID settings
• 45 CFR §164.512(b)(1)(ii), (c), disclosures about victims of abuse, neglect or domestic violence

The following documents are read together with this policy.

This policy is adopted by the governing body of 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.

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.