Abuse, Neglect, and Exploitation: Recognition and 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 makes sure everyone who works for Sample Home Health Agency, LLC (the "Agency") can recognize abuse, neglect, and exploitation of a patient and reports it at once to the right state agency. Every patient has the right to be free from abuse, neglect, and exploitation by an Agency employee, volunteer, or contractor (26 TAC §558.282(f)(6)), and, if the Agency is Medicare-certified, to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect, and misappropriation of property (42 CFR §484.50(c)(2)).

This policy covers abuse, neglect, and exploitation of a patient by anyone: Agency staff, family members, other caregivers, neighbors, or strangers, and self-neglect by a patient who cannot meet their own basic needs. It also covers injuries of unknown source and misappropriation of patient property. It applies to adults and children.

For the purposes of this policy, the following terms have the meanings below. 26 TAC Chapter 558 says "client" and 42 CFR Part 484 says "patient"; in this policy the two words mean the same person.

The Agency does not tolerate abuse, neglect, or exploitation. Any person who has cause to believe that a patient is being, or has been, abused, neglected, or exploited reports it immediately to the state agency in Table 1. The duty is personal: it applies to every person, including those whose communications are otherwise confidential, such as nurses and social workers (Tex. Hum. Res. Code §48.051(c)), and telling a coworker or supervisor does not satisfy it. Staff also report what they found immediately to the Agency (42 CFR §484.50(e)(2)), so the Agency can protect the patient and investigate.

No one, including the Administrator, decides that an allegation is not credible and need not be reported. Screening or delaying a report for an internal review is a violation of this policy.

HHSC Provider Letter PL 2023-12 tells home and community support services agencies that, from September 1, 2023, abuse, neglect, and exploitation by an agency employee, volunteer, contractor, or subcontractor is reported to HHSC, regardless of payer, and abuse, neglect, or exploitation by anyone else, and self-neglect, is reported to DFPS. If the reporter is unsure which agency to call, they call HHSC on 1-800-458-9858 and follow the intake worker’s direction; a report is never delayed while deciding.

Staff in patients’ homes are often the first to notice. Signs include:

• Physical: unexplained bruises, burns, cuts, fractures, or marks in different stages of healing; injuries that do not fit the explanation; marks from restraints; pain or bleeding in the genital area.
• Neglect: weight loss, dehydration, untreated pressure injuries, soiled clothing or bedding, missing glasses, hearing aids, or dentures, no food, no heat or cooling, prescriptions not filled.
• Emotional: fear of a particular person, withdrawal, agitation, sudden change in behavior, a caregiver who will not let you see the patient alone.
• Financial: missing money, medication, or belongings; unpaid bills despite enough income; new "best friends"; sudden changes to a will, bank account, or power of attorney; a staff member receiving gifts or loans.
• Self-neglect: unsafe or unsanitary living conditions, refusing needed care while unable to understand the risks, hoarding that blocks exits.

1. Make the patient safe. If the patient is in immediate danger or needs medical care, call 911. Do not leave the patient alone with the person suspected. Do not confront the suspected person.
2. Report to the state. Call the number in Table 1 yourself, immediately, and for staff-perpetrated abuse never later than 24 hours. Give the information the intake worker asks for: the patient’s name, age, and address; the name and address of anyone responsible for the patient’s care; the nature and extent of the patient’s condition; how you know; and anything else relevant (Tex. Hum. Res. Code §48.051(d)). Write down the date, time, intake number, and intake worker’s name.
3. Tell the Agency immediately. Call the supervising nurse or the Administrator on (512) 555-0100 (after hours, (512) 555-0199). If they cannot be reached, call Jo Sample. Telling the Agency is in addition to, never instead of, your own report.
4. Write it down. Complete the Incident Report (Form TX-HH-QA-02-A) the same day with the facts, in the words people used. Document your clinical findings objectively in the clinical record (for example, the size, color, and location of a bruise) without opinions.
5. Preserve evidence. Do not clean, move, or throw away anything that may be evidence unless it is needed for the patient’s immediate care.
6. Keep it confidential. Discuss the matter only with the Administrator, the supervising nurse, investigators, and law enforcement.

• Confirms the state report was made, and makes it if it has not been, immediately and never later than 24 hours (Policy TX-HH-SG-02).
• For an allegation against Agency staff: starts an investigation immediately, removes the person from all patient contact pending the outcome, and sends Form 3613 to HHSC no later than the 10th day after the report (26 TAC §558.250(b); Policy TX-HH-QA-02).
• Notifies the patient’s physician or allowed practitioner and, unless that person is suspected, the patient’s representative, and updates the plan of care to protect the patient.
• Tells the patient, or representative, that a report was made, unless doing so would place the patient at risk of serious harm or the person to be told is suspected (45 CFR §164.512(c)(2)).
• Cooperates fully with HHSC, DFPS, and law enforcement.
• Reviews every allegation through QAPI under Policy TX-HH-QA-01.

• A person who reports in good faith is immune from civil or criminal liability for the report (Tex. Hum. Res. Code §48.054).
• A person who has cause to believe an elderly person or person with a disability has been abused, neglected, or exploited and knowingly fails to report commits a Class A misdemeanor (Tex. Hum. Res. Code §48.052(a)).
• Knowingly or intentionally making a report that the person knows is false or lacks factual foundation is a Class A misdemeanor (Tex. Hum. Res. Code §48.053).
• The Agency does not retaliate against anyone who reports or cooperates in good faith (26 TAC §558.250(e); Tex. Health & Safety Code §142.0093), and does not reduce, change, or end a patient’s services because a report was made.

At the start of care, the admitting clinician gives each patient, and the patient’s representative where applicable, Form TX-HH-SG-01-A, which explains the patient’s right to be free from abuse, neglect, and exploitation and how to report directly to HHSC and DFPS, and files the patient’s signed acknowledgment in the clinical record (26 TAC §558.301(a)(9)(K)). The HHSC and DFPS numbers are also posted in the Agency office.

Accountability under this policy is allocated as follows.

Each patient’s acknowledgment of Form TX-HH-SG-01-A is kept in the clinical record (Policy TX-HH-REC-01). Staff acknowledgments of this policy are kept in the personnel record. The Administrator keeps a log of every report (date and time of cause to believe, date and time reported, agency called, intake number) and the confidential file under Policy TX-HH-QA-02. Each quarter, as the Agency’s own standard, the QAPI Committee reviews the log for timeliness and themes and audits a sample of new admissions for the acknowledgment.

Every employee, contractor, and volunteer is trained on this policy at orientation, before first patient contact, and signs an acknowledgment; training is repeated annually as the Agency’s own standard. Training covers warning signs, Table 1, the steps in Section 6, and the legal protections and penalties, and uses home health scenarios such as injuries of unknown source found during a visit.

This policy implements the following authorities.

• Texas Human Resources Code §48.051, Report; §48.052, Failure to Report; Penalty; §48.053, False Report; Penalty; §48.054, Immunity
• Texas Family Code §261.101, Persons Required to Report; Time to Report
• Texas Health and Safety Code §142.018, Reports of Abuse, Exploitation, or Neglect; §142.0093, Retaliation Prohibited
• 26 Texas Administrative Code §558.249, Self-Reported Incidents of Abuse, Neglect, and Exploitation; §558.250, Agency Investigations
• 26 Texas Administrative Code §558.282(f)(6), Client Rights; §558.301(a)(9)(K), Client Records
• HHSC Provider Letter PL 2023-12, Reporting Abuse, Neglect, and Exploitation for HCSSAs (revised May 22, 2023)
• 42 CFR §484.50(c)(2) and (e)(2), Patient rights
• 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 Home Health 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.