Recognizing and Reporting Abuse, Neglect and Exploitation of Adults and Children

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.

This policy protects patients, and children and other vulnerable people in the homes the Agency visits, by making sure that everyone working for Sample Agency, LLC (the "Agency") knows the signs of abuse, neglect and exploitation and reports them to the right place at once.

This policy covers suspected abuse, neglect, self-neglect and exploitation of any adult patient or other disabled adult the staff member encounters through work, and suspected abuse, neglect or dependency of any child, by anyone: a family member, caregiver, neighbor, facility staff, or Agency staff. It applies in homes, nursing facilities, adult care homes, ICF/IID, hospitals and the Agency's own facilities.

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

"Any person having reasonable cause to believe that a disabled adult is in need of protective services shall report such information to the director." (G.S. 108A-102(a)). "Any person or institution who has cause to suspect that any juvenile is abused, neglected, or dependent, as defined by G.S. 7B-101, or has died as the result of maltreatment, shall report the case of that juvenile to the director of the department of social services in the county where the juvenile resides or is found." (G.S. 7B-301(a)). Every patient has the right "To be free of mental and physical abuse, neglect, and exploitation." (G.S. 131E-144.3(6), applied by 10A NCAC 13K .0604(a)). If the Agency is Medicare-certified, every patient also has the right to be free from mistreatment, neglect, or verbal, mental, sexual and physical abuse, including injuries of unknown source, and misappropriation of patient property (42 CFR §418.52(c)(6)). Every staff member reports suspected abuse, neglect and exploitation as this policy sets out.

Staff look for these signs on every visit. One sign is not proof; a pattern, an explanation that does not fit, or a patient's own words are reasons to report. Staff do not need proof, only reasonable cause to believe (adults) or cause to suspect (children).

A patient's informed decision to refuse food, fluids, treatment or a visit, or to die at home, is the patient's right (Policy NC-HSP-PR-01) and is not, by itself, neglect. Expected changes at the end of life, such as weight loss or skin breakdown despite good care, are documented and explained to the family. When staff are unsure, they talk to the social worker or the Director of Nursing at once, and they report if they still have reasonable cause to believe.

1. If anyone is in immediate danger, call 911 first.
2. Tell the Administrator, or the person acting under the order of authority, at once by telephone. For an alleged violation by anyone furnishing services on behalf of the Agency, this report to the Administrator must be immediate (42 CFR §418.52(b)(4)(i)); the Agency applies the same rule to every suspicion (Agency standard).
3. Report to the county DSS: for an adult, the director of the department of social services in the county where the adult lives or is present (G.S. 108A-101(c), 108A-102), orally (by telephone or in person) or in writing; county department of social services contacts are listed at https://www.ncdhhs.gov/divisions/social-services/local-dss-directory, and the NCDHHS Customer Service Center (1-800-662-7030) can help find the right county office. If anyone is in immediate danger, call 911 first.; for a child, the director of the department of social services in the county where the child lives or is found (G.S. 7B-301), orally, by telephone or in writing; and, when a child has been the victim of a violent offense, a sexual offense or misdemeanor child abuse, the local law enforcement agency in that county, immediately (G.S. 14-318.6). Use the county numbers on the Agency list ((919) 555-0121) or https://www.ncdhhs.gov/divisions/social-services/local-dss-directory. Report the same day you form the suspicion (Agency standard).
4. If you are 18 or older and you know or should reasonably know that a child is the victim of a violent offense, a sexual offense or misdemeanor child abuse, you "shall immediately report the case of that juvenile to the appropriate local law enforcement agency in the county where the juvenile resides or is found." (G.S. 14-318.6(b)). This is in addition to the DSS report.
5. If the patient lives in a nursing facility or ICF/IID and the person suspected is not connected with the Agency, the Agency also reports to the facility administrator within 24 hours of becoming aware (42 CFR §418.112(c)(8), if Medicare-certified; Policy NC-HSP-FAC-01). If a crime is suspected against a resident of a long-term care facility, also follow the 2-hour and 24-hour reports in Policy NC-HSP-QA-02, Section 6.
6. If the person suspected is an Agency staff member, contractor or volunteer, also follow Policy NC-HSP-ANE-02 at once.
7. Write down the facts on Form NC-HSP-QA-02-A and in the clinical record: what you saw and heard, the patient's own words, the date and time, who you reported to and when, and the name of the person who took the DSS report.

The report may be made orally or in writing (G.S. 108A-102(b); for children, G.S. 7B-301(a)). For an adult, "The report shall include the name and address of the disabled adult; the name and address of the disabled adult's caretaker; the age of the disabled adult; the nature and extent of the disabled adult's injury or condition resulting from abuse or neglect; and other pertinent information." (G.S. 108A-102(b)). Also tell DSS that the person is a hospice patient, his or her prognosis and care needs, and the name and number of the Agency contact (the social worker or Administrator), so DSS can plan its response with the Agency (Agency standard).

The staff member who has the concern makes sure the report is made. The social worker or the Administrator may make the call together with the staff member, but no one may tell a staff member not to report or to wait. If the county office is closed, call its after-hours number, or 911 or local law enforcement if there is danger (Agency standard). A report made in good faith is protected: anyone who makes a report under G.S. 108A-102, testifies in a judicial proceeding arising from it, or takes part in a required evaluation is immune from civil or criminal liability unless acting in bad faith or with a malicious purpose (G.S. 108A-102(c)).

• Do not investigate, interview the patient in detail, or confront the person suspected; DSS and law enforcement investigate.
• Do not promise the patient or family that you will keep it secret; explain kindly that you must tell people who can help.
• Do not move, clean or throw away anything that may be evidence, unless it is needed for the patient's immediate care.
• Do not discuss the report with anyone who does not need to know (Policy NC-HSP-PRV-01). HIPAA permits the disclosure of PHI needed for an abuse report required by law (45 CFR §164.512(c)).

The county director must start an evaluation immediately if the report says the adult is in danger of death, within 24 hours if there is danger of irreparable harm, and within 72 hours otherwise (G.S. 108A-103(d)); this is the county's duty and is given here for information so staff know what to expect. The Agency:

• Cooperates with DSS and law enforcement and gives the information they ask for, through the social worker or Administrator.
• Holds an IDT review within one working day to update the care plan for the patient's safety, for example more visits, a different caregiver, inpatient respite or a change of setting (Agency standard).
• Secures the patient's controlled substances (for example, a lock box or fewer doses in the home) if diversion is suspected (Policy NC-HSP-MED-02).
• Supports the patient, the family and the staff member who reported; the social worker and clergy member offer support.
• Logs the report in the incident log so the quality program can see trends (Policy NC-HSP-QA-02).

At admission every patient receives Form NC-HSP-ANE-01-A with the rights notice (Policy NC-HSP-PR-01). It explains, in plain language and in Spanish, that the patient has the right to be free from abuse, neglect and exploitation, how to tell the Agency, and how to report directly to the county DSS, law enforcement and the Division of Health Service Regulation.

Not reporting is serious. Failing to report a juvenile as G.S. 7B-301(a) requires is a Class 1 misdemeanor (G.S. 7B-301(b)). An employee who fails to report, or who discourages or delays another person's report, faces discipline up to termination (Agency standard). No one is disciplined or retaliated against for making a good faith report (42 CFR §418.52(b)(1)(iv)).

Each role named below carries the duties shown.

Each report is documented in the clinical record and in the incident log, with the date and time, the agency and person reported to, and the outcome when known. The Administrator keeps the incident file for at least six years (Agency standard). The quality lead reviews the log each quarter for timely reporting and trends (Policy NC-HSP-QA-02).

All staff and patient family volunteers are trained on this policy at orientation, as part of patient rights training (10A NCAC 13K .0402(b)(14)), and every year (Agency standard), including how to find the county DSS number and practice cases about self-neglect, exploitation and children in the home. Managers and on-call nurses are trained on Sections 6 and 7 before taking call.

This policy implements the following authorities.

• G.S. 108A-101, definitions; G.S. 108A-102, duty to report, content of report, immunity; G.S. 108A-103, duty of the director
• G.S. 7B-101, definitions; G.S. 7B-301, duty to report abuse, neglect, dependency or death due to maltreatment
• G.S. 14-318.6, duty to report crimes against juveniles
• G.S. 131E-144.3(6), right to be free of abuse, neglect and exploitation (applied by 10A NCAC 13K .0604(a))
• 10A NCAC 13K .0402(b)(14), patient rights training
• 42 CFR §418.52(b)(4), (c)(6); §418.112(c)(8) (Medicare-certified hospices)
• 45 CFR §164.512(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.