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 often frail, confused, bed-bound and dependent on others. Hospice staff are in their homes and facilities more than anyone else outside the family. This policy makes sure that Sample Agency, LLC (the "Agency") never misses or delays a report of suspected abuse, neglect or exploitation, that each patient's right "to be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property" is protected (42 CFR §418.52(c)(6)), and that every Pennsylvania reporting duty is met.

Suspected abuse, neglect, exploitation or abandonment of any patient aged 18 or older, by anyone: family members and other caregivers, friends, strangers, other residents of a facility, facility staff, and Agency staff, contractors and volunteers. Self-neglect is covered in Section 9. Children are covered in Policy PA-HSP-ANE-03, but the protective services report in Section 6 applies to patients of any age.

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" (35 P.S. §10225.701(a)(1)). Within 48 hours of making the oral report, the employee or administrator makes a written report to the protective services agency (35 P.S. §10225.701(a)(2)). For an adult aged 18 to 59, the Adult Protective Services Act imposes the same duty for abuse or neglect (35 P.S. §10210.501(a)). In addition, the Agency ensures that "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 furnishing services on behalf of the hospice, are reported immediately by hospice employees and contracted staff to the hospice administrator" (42 CFR §418.52(b)(4)(i)), and the Administrator notifies the Department of Health in writing of every complaint of patient abuse, "whether or not confirmed by the facility" (28 Pa. Code §51.3(g)(6); Policy PA-HSP-GOV-04).

The Agency's own standard is broader than the minimum: staff report suspected neglect, exploitation and abandonment of a patient of any age as well as abuse. Reasonable cause to suspect is enough. Staff do not need proof, do not need to know who is responsible, and do not investigate before reporting.

Signs that should make staff suspect abuse, neglect or exploitation include those in Table 1. Many hospice patients bruise easily, lose weight and become confused because of their illness; staff report when an explanation does not fit, when a pattern changes, or when the patient or someone else says something has happened.

Table 2 sets out the reports. The employee who has reasonable cause to suspect makes the reports personally. The employee may ask the Administrator, or the person the Administrator designates, to make or help make the reports (6 Pa. Code §15.151(d); 35 P.S. §10225.701(a)(3)), but the employee stays responsible for making sure they are made. If the patient is in immediate danger, call 911 first.

Department of Aging line: the telephone number the Department of Aging publishes for facilities' oral mandatory abuse reports, (717) 265-7887 on the date of this version (Department of Aging, Older Adult Protective Services Annual Report, Fiscal Year 2023-2024). When the line offers a menu, choose the Department of Aging. The Administrator checks the number on the Department of Aging website at each review. If the call cannot be completed, the employee tells the protective services unit and the Administrator, who keeps trying and records each attempt.

For a patient aged 18 to 59 who has a physical or mental impairment that substantially limits one or more major life activities, the Adult Protective Services Act also applies. Its reports are made in addition to the reports in Table 2, because both Acts cover a hospice patient of this age and the Department of Aging reports that facilities report to both departments.

Under the Adult Protective Services Act, the employee notifies the Administrator immediately after the report to law enforcement "unless such notification would jeopardize the investigation or subject the recipient to further risk" (35 P.S. §10210.501(b)(1)). The Act also treats the reporting duty as satisfied when the report is submitted to the Department of Human Services incident reporting system (35 P.S. §10210.501(a)(3)); the Agency does not use that system unless the Department of Human Services gives it access, and reports by telephone and in writing.

The written report is made on the form the Department of Aging (or, for Table 3, the Department of Human Services) supplies or approves, and includes at least: the name, age and address of the patient; the name and address of the patient's guardian, attorney-in-fact or next of kin; the Agency's name and address; the nature of the alleged offense or a description of the incident; and any specific comments or observations that are directly related to the alleged incident and the individuals involved (35 P.S. §10225.701(c); 6 Pa. Code §15.153; 35 P.S. §10210.501(c)). Staff describe what they saw and heard in the patient's own words where possible, and do not guess. Staff do not photograph injuries for the report unless the Administrator or law enforcement asks; injuries are described and measured in the clinical record.

A staff member who suspects abuse, neglect or exploitation:

1. Makes the patient safe. If anyone is in immediate danger, calls 911. Gives care the patient needs. Does not confront the suspected abuser or promise the patient to keep a secret.
2. Makes the oral report to protective services at once (Table 2), and, if a serious category applies, to law enforcement at once. If the patient is aged 18 to 59, also follows Table 3.
3. Tells the Administrator immediately after the report (Table 2). After hours, calls the on-call manager on (717) 555-0199, who reaches the Administrator.
4. Makes or confirms the Department of Aging oral report during the current business day or at the opening of the next business day when a serious category applies. The Administrator may make this call with the employee.
5. Documents in the clinical record the facts observed, the patient's words, the care given and the time and recipient of each report, without opinion and without copying the report itself into the record.
6. Completes the written report or reports within 48 hours and gives a copy to the Administrator.
7. The Administrator sends the written notice to the Department of Health (Policy PA-HSP-GOV-04), starts the investigation and protective steps in Policy PA-HSP-ANE-02, and, if the patient lives in a facility, makes sure the facility administrator is told (Table 2).
8. If the patient has died and abuse is suspected as a cause, the staff member does not disturb the body or the scene beyond what is necessary, and makes the reports above; the protective services agency reports to the coroner (6 Pa. Code §15.154(b); 35 P.S. §10225.702(b)).

• Self-neglect and need for protective services. A patient aged 60 or older who is not able to care for themselves and has no responsible caretaker may be an older adult in need of protective services. Any person having reasonable cause to believe that an older adult is in need of protective services may report to the protective services agency (35 P.S. §10225.302(a)). As the Agency's own standard, staff make that report and tell the Administrator.
• Abuse by Agency staff, contractors or volunteers. The same reports are made, and the Administrator acts at once under Policy PA-HSP-ANE-02 to protect patients, including a plan of supervision or suspension.
• Abuse in a facility. Staff make the reports in Table 2 and Table 3 whether the suspected abuser is facility staff, another resident or a visitor. The facility's own staff have their own duty to report; the Agency does not rely on it.
• Misappropriation of drugs. Missing controlled substances are also handled under Policy PA-HSP-MED-02.
• Telling the patient. The patient or personal representative is told that a report has been made, unless the Administrator believes telling them would place the patient at risk of serious harm or the representative is the suspected abuser (45 CFR §164.512(c)(2)).

A person or entity who takes discriminatory, retaliatory or disciplinary action against an employee or other person who makes a report, or who cooperates with protective services or the Department of Aging, or against a victim of abuse, violates the Older Adults Protective Services Act and may be sued for damages (6 Pa. Code §15.22(a)). A person who participates in making a report is immune from civil or criminal liability because of that action unless the person acted in bad faith or with malicious purpose (6 Pa. Code §15.22(b)). Any person with knowledge sufficient to make a report must be free from intimidation by an employer or anyone else (6 Pa. Code §15.22(c)). Under the Adult Protective Services Act, a person required to report has the protections and remedies of the Whistleblower Law and may not be subject to retaliatory action for reporting (35 P.S. §10210.506(d)). The identity of the person who made a report is confidential (6 Pa. Code §15.157(e)). The Agency never retaliates against anyone who reports in good faith.

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 (35 P.S. §10225.706(c); 6 Pa. Code §15.158(c); 35 P.S. §10210.506(c)). An administrator or facility owner who intentionally or willfully fails to comply or obstructs compliance, or who intimidates or retaliates against an employee who complies in good faith, is subject to an administrative civil penalty of not more than $2,500, and one who intentionally or willfully fails to comply or obstructs compliance commits a misdemeanor of the third degree (6 Pa. Code §15.158(a)-(b); 35 P.S. §10210.506(a)-(b)). Failure to report is also serious misconduct under Agency personnel procedures.

The Administrator posts notices in conspicuous and accessible locations and uses other appropriate means to tell employees, patients and others of the protections and obligations under the Act, and keeps them informed (6 Pa. Code §15.22(d)). The Agency posts the notice at each office, includes it in the orientation materials, and gives each patient and family the Abuse, Neglect and Exploitation Reporting Notice (Form PA-HSP-ANE-01-A) at admission, with the protective services and statewide numbers and, for patients in a nursing facility or personal care home, the long-term care ombudsman on (717) 555-0120.

Accountability under this policy is allocated as follows.

Copies of oral report details (date, time, person spoken to), written reports, notices and related correspondence are kept in a confidential protective services file, separate from the clinical record and from personnel files, for at least six years (the Agency's own standard). Reports are confidential under 35 P.S. §10225.705 and 6 Pa. Code §15.157. The clinical record shows the facts observed, the care given and that reports were made. Each quarter the Administrator compares the incident log, complaint log and clinical notes with the report file and reports the number, type and timeliness of reports to the QAPI program (Policy PA-HSP-QA-01).

Every employee, contracted staff member and volunteer is trained on this policy at orientation, before working alone with patients, including the warning signs, Table 2, Table 3 and the protections for reporters (6 Pa. Code §15.146(a)(4) for provisional employees; Policy PA-HSP-HR-01), and every year after that (the Agency's own standard). The Department of Aging's free online mandatory abuse reporting course may be used as part of this training. Training records are kept in the personnel file.

This policy implements the following authorities.

• Older Adults Protective Services Act, 35 P.S. §10225.101 et seq., including §10225.103 (definitions), §10225.302 (reporting), §§10225.701-10225.708 (reporting suspected abuse by employees)
• 6 Pa. Code §15.2 (definitions), §15.22 (safeguards for those who make reports), §§15.151-15.159 (reporting suspected abuse)
• Adult Protective Services Act, Act 70 of 2010, 35 P.S. §10210.101 et seq., including §10210.103 and §§10210.501-10210.507
• 28 Pa. Code §51.3(f)-(g)(6), notification of complaints of patient abuse
• 42 CFR §418.52(b)(4) and (c)(6), patient rights and reporting of alleged violations
• 42 CFR §418.112(c)(8), reports to a nursing facility or ICF/IID administrator
• 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 16 is amended, the amendment is recorded in this table and a new version of this policy is issued.