Recognizing and Reporting Abuse, Neglect and Exploitation of Adults

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 frail, often depend on others for every need, and may not be able to speak up for themselves. Missouri law requires people who care for them to report suspected abuse and neglect immediately. This policy makes sure every member of the Agency knows the signs, knows that the duty to report is personal, and knows exactly how to report to the State and inside the Agency.

This policy covers every adult the Agency's staff come into contact with in the course of their work: patients, and also other adults in the home such as a frail spouse. It covers the patient's home, a relative's home, nursing facilities, assisted living and residential care facilities, inpatient facilities and any other setting.

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

Missouri law says that the listed professionals and other persons "shall be required to immediately report or cause a report to be made to the department" when they have reasonable cause to suspect that an eligible adult has been subjected to abuse or neglect, or observe the adult being subjected to conditions or circumstances which would reasonably result in abuse or neglect (RSMo §192.2405.1(2)). Any person with reasonable cause to suspect that an eligible adult presents a likelihood of suffering serious physical harm, or bullying, and is in need of protective services must also report (RSMo §192.2405.1(1)).

As an Agency standard, every employee, contracted staff member and volunteer reports suspected abuse, neglect, bullying or exploitation of any adult to the Department immediately, whether or not the law names their job, and tells the Administrator at once. If the Agency is Medicare-certified, every alleged violation by anyone furnishing services on behalf of the hospice must also be reported immediately to the Administrator (42 CFR §418.52(b)(4)(i)); Policy MO-HSP-QA-02 then applies.

The law does not require a duly ordained minister, clergy, religious worker or Christian Science practitioner, while functioning in his or her ministerial capacity, to report a privileged communication made to him or her in that professional capacity (RSMo §192.2405.1). This exception covers only the privileged communication itself. Anything a spiritual counselor sees, or learns outside a privileged communication, is reported like any other observation. A spiritual counselor who is unsure asks the Administrator for guidance without revealing the communication.

Hospice patients bruise easily, lose weight and develop skin breakdown as part of their illness, so a single sign may have an innocent cause. Look at the whole picture, write down what you see, and report when the explanation does not fit. When in doubt, report.

Respect for choices: a competent patient's decision to refuse a treatment, a visit or a move is a right, not neglect. A family that cares for the patient according to the plan of care and the patient's wishes is not neglecting the patient because the patient declines as the illness progresses. Report when a person with a duty to provide care fails to provide it and the failure puts the patient in danger, or when a patient who cannot protect his or her own interests is at risk.

1. If anyone is in immediate danger, call 911 first.
2. Report to the Department immediately, before the end of your visit if you can: the Missouri Department of Health and Senior Services Adult Abuse and Neglect Hotline at 1-800-392-0210 (seven days a week, 7:00 a.m. to 8:00 p.m.), or online at any time through the Missouri Adult Abuse and Neglect Online Reporting System at https://moapss.health.mo.gov/. Relay service: Relay Missouri 1-800-735-2966 (text) or 1-800-735-2466 (voice). If the telephone line is closed, report online at https://moapss.health.mo.gov/, which is open at all times.
3. Make the report yourself. Telling your supervisor or the Administrator does not meet your legal duty, and no one in the Agency may tell you not to report or to wait.
4. Give what you know: the name, age and address of the adult; the name and address of anyone responsible for the adult's care; the nature and extent of the adult's condition; and any other relevant information (RSMo §192.2410.1). The report may be made orally or in writing. Write down the date, time and any intake number the Department gives you.
5. Tell the Administrator ((573) 555-0111) immediately after making the report. If the suspected abuser works for the Agency, Policy MO-HSP-QA-02 applies at once.
6. Complete Form MO-HSP-ANE-01-A the same day and give it to the Administrator. It is kept in a confidential file, not in the clinical record.
7. In the clinical record, write only objective facts about the patient's condition and the care given (what you saw, what the patient said in his or her own words, measurements), not opinions about who is to blame.
8. Do not confront the person you suspect, and do not promise the patient that you will keep the concern secret.

RSMo §198.070 adds duties when the adult is a resident of a facility (a skilled nursing, intermediate care, assisted living or residential care facility).

• When a nurse, physician, social worker, minister, pharmacist, therapist, other health practitioner, home health agency employee, or any other person with the care of a person 60 or older or an eligible adult has reasonable cause to believe that a resident of a facility has been abused or neglected, he or she must immediately report or cause a report to be made to the Department (RSMo §198.070.1). Use the same route: the Missouri Department of Health and Senior Services Adult Abuse and Neglect Hotline at 1-800-392-0210 (seven days a week, 7:00 a.m. to 8:00 p.m.), or online at any time through the Missouri Adult Abuse and Neglect Online Reporting System at https://moapss.health.mo.gov/.
• The report contains the name and address of the facility, the name of the resident, information about the nature of the abuse or neglect, the name of the complainant, and any other information that might help an investigation (RSMo §198.070.2(1)).
• For suspected sexual assault of a resident, a report must also be made to the appropriate local law enforcement agency (RSMo §198.070.2(2)).
• Failing to report within a reasonable time is a class A misdemeanor (RSMo §198.070.3).
• The Department must initiate an investigation within 24 hours of receiving a report (RSMo §198.070.6), and must notify the reporter in writing of receipt of the report and of the initiation of the investigation within five working days (RSMo §198.070.10).
• If the Agency is Medicare-certified, it also reports alleged violations by anyone unrelated to the hospice to the facility administrator within 24 hours of becoming aware of them (42 CFR §418.112(c)(8); Policy MO-HSP-FAC-01). The Agency does not tell the facility administrator first if the administrator is the person suspected.
• Residents and families can also get advocacy from the Missouri Long-Term Care Ombudsman Program, 912 Wildwood Drive, P.O. Box 570, Jefferson City, MO 65102-0570, 1-800-309-3282, LTCOmbudsman@health.mo.gov. The ombudsman does not replace the report to the Department.
• No person who directs or exercises authority in a facility may evict, harass, dismiss or retaliate against a resident or employee because a report was made (RSMo §198.070.11). Anyone who knowingly files a false report of elder abuse or neglect commits a crime under RSMo §565.189 (RSMo §198.070.9).

Report to the Department exactly as in Section 7, and tell the Administrator at once. The Administrator removes the person from patient contact while the matter is investigated and follows Policy MO-HSP-QA-02, including the report of a verified violation to the Department within five working days. Any hospice or employee of a hospice who knowingly abuses or neglects any client, or misappropriates the property of any client, is guilty of a class E felony (RSMo §197.266). The Department receives and investigates complaints of abuse, neglect or misappropriation by a hospice or its employees (RSMo §197.268; 19 CSR 30-35.030(2)(B)) and may place a person found to have abused or neglected a client on the Employee Disqualification List (RSMo §192.2490; Policy MO-HSP-HR-03).

• No employee, contractor or volunteer is disciplined, threatened or treated differently for making a report in good faith or for helping an investigation (Agency standard). A staff member who suffers retaliation tells the Administrator or the chair of the governing body.
• The Agency keeps the identity of the reporter confidential and shares report details only with people who need them to protect the patient or to investigate (Agency standard). Reports about facility residents are confidential as RSMo §198.070.8 and §192.2500 provide.
• The Agency cooperates with the Department's investigation and gives access to records and staff as the law allows (Policy MO-HSP-PRV-01).
• Care continues. The IDG meets as soon as possible to update the plan of care, add social work and spiritual support, consider respite or a change of setting, and plan visits so that the patient is not left alone with a person who may be harmful.

Each role named below carries the duties shown.

The following records are kept and checked:

• Form MO-HSP-ANE-01-A for every report, kept in the Administrator's confidential file for at least six years (Agency standard).
• Training records showing that every staff member and volunteer has been trained in this policy.
• Each quarter the Administrator reviews the reports for timeliness (observation to report) and patterns, and gives an anonymous summary to the QAPI program (Policy MO-HSP-QA-01).

Every employee, contracted staff member and volunteer is trained in this policy at orientation, before patient contact, and every year: the definitions, the signs in hospice care, the personal duty to report immediately, how to report by telephone and online, facility residents, and protection from retaliation. Training uses real hospice scenarios, including the difference between disease progression and neglect.

This policy implements the following authorities.

• RSMo §192.2400, definitions; §192.2405, mandatory reporters; §192.2410, contents of reports; §192.2490, Employee Disqualification List; §192.2500, confidentiality
• RSMo §565.188, failure to report elder abuse or neglect; §565.189, false reports
• RSMo §198.006, facility definitions; §198.070, abuse or neglect of facility residents
• RSMo §197.250(1) and (6), abuse and neglect; §197.266, penalty; §197.268, complaints
• 19 CSR 30-35.010(1)(F)3.A, patient rights; 19 CSR 30-35.030(2)(B), complaints
• 42 CFR §418.52(b)(4) and (c)(6); §418.112(c)(8) (Medicare-certified hospices)

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.