Abuse, Neglect, and Exploitation of Adults: Mandatory Reporting

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 of Sample Agency, LLC (the "Agency") from abuse, neglect, exploitation and abandonment by making sure every staff member knows the signs, reports at once to the right authority, and is protected for doing so.

This policy covers suspected abuse of any patient by anyone: Agency staff, family members, caregivers, other household members, other providers or strangers, and self-neglect. It applies on and off visits whenever staff learn of the concern through their work.

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

"An employee or an administrator who has reasonable cause to suspect that a recipient is a victim of abuse shall immediately make an oral report to the agency" (OAPSA §701(a)(1), 35 P.S. §10225.701(a); 6 Pa. Code §15.151(a)(1)). The employee notifies the Administrator immediately following the report (§701(a)(1); §15.151(b)). "Within 48 hours of making the oral report, the employee or administrator shall make a written report to the agency" (§701(a)(2); §15.151(a)(2)). For a patient aged 18 to 59 with a physical or mental impairment, the Adult Protective Services Act sets the same duty for suspected "abuse or neglect" (35 P.S. §10210.501(a)).

If there is reasonable cause to suspect that a recipient is the victim of sexual abuse, serious physical injury or serious bodily injury, or that a death is suspicious, the employee or Administrator also immediately makes an oral report to law enforcement officials, notifies the Administrator immediately after, makes an oral report to the Department of Aging "during the current business day or, if the incident occurs after normal business hours, at the opening of the next business day", and makes a written report within 48 hours of the oral report to law enforcement officials and the agency (OAPSA §701(b); 6 Pa. Code §15.152(a); for adults 18 to 59, a joint written report under 35 P.S. §10210.501(b)).

The Agency does not require staff to get permission before reporting, does not screen or investigate before the report is made, and never retaliates against anyone who reports. Staff may ask the Administrator to make, or help them make, the reports (OAPSA §701(a)(3); §15.151(d)), but the duty stays with the staff member until the report is made. The Agency also gives the Department of Health immediate written notice of every complaint of patient abuse, "whether or not confirmed by the facility" (28 Pa. Code §51.3(g)(6); Policy PA-HH-QA-02).

If the Agency is Medicare-certified, staff who identify, notice or recognize mistreatment, neglect, verbal, mental, sexual or physical abuse, including injuries of unknown source, or misappropriation of patient property must report these findings "immediately to the HHA and other appropriate authorities in accordance with state law" (42 CFR §484.50(e)(2)). The Agency treats injuries of unknown source, verbal abuse and misappropriation of property as reportable under this policy for every patient.

1. Make the patient safe. If the patient is in immediate danger, call 911 first. Do not confront the suspected abuser or put yourself at risk.
2. Make the oral report immediately, yourself. Call the local protective services agency at (717) 555-0121, or the Statewide Elder Abuse Helpline at 1-800-490-8505, which is answered 24 hours a day, seven days a week, and also takes Adult Protective Services reports. The route is the protective services unit of the local Area Agency on Aging, or the Statewide Elder Abuse Helpline at 1-800-490-8505, which is answered 24 hours a day, seven days a week and also takes Adult Protective Services reports for adults aged 18 to 59 with a disability. Ask the agency whether any additional reports apply (OAPSA §701(a)(1)).
3. Sexual abuse, serious physical or bodily injury, or suspicious death: also call law enforcement immediately (911 or the local police) and make an oral report (OAPSA §701(b); 6 Pa. Code §15.152(a)(1)).
4. Tell the Administrator immediately after each report (Pat Sample, (717) 555-0111; if not available, Jo Sample, (717) 555-0112; after hours (717) 555-0199). If the concern is about the Administrator, tell the alternate administrator or the supervising nurse and still make the report yourself.
5. Patient under 18: also report to ChildLine at 1-800-932-0313 under Policy PA-HH-SG-02.
6. Write it down. Complete Form PA-HH-SG-01-B the same day, with facts only: what you saw and heard, the patient’s own words in quotation marks, dates and times, who you called and when, and the name of the person who took the report. Document your clinical findings in the clinical record without opinions.
7. Written report within 48 hours. Make the written report to the protective services agency, on the form the Department of Aging supplies or approves, within 48 hours of the oral report (6 Pa. Code §15.151(a)(2), §15.153); for the reports in step 3, also to law enforcement within 48 hours (§15.152(a)(3)). The Administrator helps you complete it if you ask, and keeps a copy.
8. Do not investigate on your own, question the patient beyond what is needed for safety, or tell the suspected abuser about the report.

• Department of Aging. For sexual abuse, serious physical or bodily injury or suspicious death, the Administrator makes sure the oral report to the Department of Aging is made during the current business day, or at the opening of the next business day if the incident occurs after normal business hours (6 Pa. Code §15.152(a)(2)), using the contact route the protective services agency or the Department of Aging gives at the time of the report.
• Department of Health. The Administrator sends immediate written notice of the abuse complaint to the director of the Division of Home Health on Form PA-HH-QA-02-B, whether or not the complaint is confirmed (28 Pa. Code §51.3(g)(6); Policy PA-HH-QA-02). Administrators and employees must comply with the reporting requirements of the Commonwealth licensing agency as well as OAPSA (6 Pa. Code §15.152(c)).
• Accused employee. If the suspected abuser is an employee or contractor, the Administrator acts under Policy PA-HH-SG-03 at once.
• Patient safety and care. The supervising nurse reviews the plan of treatment, informs the attending physician, and arranges any change in visits or services, with the patient’s agreement where the patient can give it.
• Cooperation. The Agency cooperates fully with the protective services agency, law enforcement and the Department of Health, which coordinate their investigations (6 Pa. Code §15.155(b)). For a patient aged 60 or over the protective services agency investigates; for a recipient under 60 the licensing agency investigates; reports about home health recipients are forwarded to the Department of Health (§15.155(a)(1)-(4)).
• Disclosure. Information disclosed for a report is what the report needs (45 CFR §164.512(c); Policy PA-HH-PRV-01). The Agency logs the disclosure.
• Learning. Every report is reviewed in the QAPI program (Policy PA-HH-QA-01) without identifying the reporter.

• Confidentiality. Except for reports to law enforcement officials, the release of data that would identify the person who made a report, or who cooperated in the investigation, is prohibited (OAPSA §705(e); 6 Pa. Code §15.157(e)).
• No retaliation. A person making a report or cooperating with the protective services agency, and the victim, "shall be free from any discriminatory, retaliatory or disciplinary action by an employer or by any other person or entity", and a person who violates this may be sued for damages (OAPSA §302(c)). An administrator or facility owner who intimidates or commits a retaliatory act against an employee who complies in good faith commits a violation subject to a civil penalty of not more than $2,500 (OAPSA §706(a); 6 Pa. Code §15.158(a)).
• Immunity. A person who takes part in making a report is immune from civil or criminal liability on account of the report unless the person acted in bad faith or with malicious purpose (OAPSA §302(d)); an administrator or facility is not civilly liable for any action directly related to good faith compliance (OAPSA §707; 6 Pa. Code §15.159).
• Failure to report. A person required to report suspected abuse who willfully fails to do so commits a summary offense for the first violation and a misdemeanor of the third degree for a second or subsequent violation (OAPSA §706(c); 6 Pa. Code §15.158(c)). An administrator or owner who intentionally or willfully fails to comply, or obstructs compliance, commits a misdemeanor of the third degree (§706(b); §15.158(b)).
• At the Agency, failure to report, delay, discouraging a report, or retaliation is serious misconduct leading to discipline up to dismissal.

At the start of care every patient, and the representative, receives Form PA-HH-SG-01-A, which explains in plain language what abuse, neglect and exploitation are, that the patient has the right to be free from them (42 CFR §484.50(c)(2)), and how to report: the local protective services line (717) 555-0121, the Statewide Elder Abuse Helpline 1-800-490-8505 (24 hours), ChildLine 1-800-932-0313 for children, the Department of Health home health complaint line 1-800-254-5164, 911 in an emergency, and the Agency’s complaint officer. Receipt is documented in the record.

Accountability under this policy is allocated as follows.

The Administrator keeps Forms PA-HH-SG-01-B, copies of written reports to the protective services agency and law enforcement, Department of Aging and Department of Health report records, and agency responses in a confidential file separate from personnel and clinical records, for at least seven years (Agency standard). Each quarter the Administrator checks the log to confirm that every oral report was made immediately and every written report within 48 hours, and reports the result, without names, to the QAPI Committee.

Training is delivered and recorded as follows. Frequencies marked as the Agency’s own standard are not set by rule.

This policy implements the following authorities.

• Older Adults Protective Services Act, 35 P.S. §10225.101 et seq., §302 (reporting; protection from retaliation; immunity) and Chapter 7 (§§10225.701-10225.708)
• 6 Pa. Code §15.2, Definitions; §§15.151-15.159, Reporting suspected abuse by employees
• Adult Protective Services Act (Act 70 of 2010), 35 P.S. §10210.101 et seq., §§501-505
• 28 Pa. Code §51.3(g)(6), Notification of complaints of patient abuse
• 42 CFR §484.50(c)(2) and (e)(2), Patient rights; reporting (if Medicare-certified)
• 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 Section 13 is amended, the amendment is recorded in this table and a new version of this policy is issued.