Abuse, Neglect, Self-Neglect, and Exploitation of Adults: Reporting to Adult Protective Services

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 adult patients of Sample Agency, LLC from abuse, neglect, self-neglect, and exploitation by making sure staff recognize the signs and get help to the person quickly through Adult Protective Services.

This policy covers recognizing abuse, neglect, self-neglect, and exploitation, immediate safety, who must report, how and when to report to Adult Protective Services, what to include, internal reporting, cooperation with APS, follow-up, documentation, and EPD Waiver requirements. It applies to patients 18 and older and to other adults in a patient’s home whom staff believe are at risk.

For the purposes of this policy, the following terms have the meanings below. 22-B DCMR Chapter 39 and 42 CFR Part 484 both say "patient". The District of Columbia Medicaid rules (29 DCMR Chapters 42 and 50) say "beneficiary". In this policy these words mean the same person: someone receiving home care services from the Agency.

Under D.C. Code §7-1903(a)(1), "whenever a conservator, court-appointed mental retardation advocate, guardian, health-care administrator, licensed health professional, police officer, humane officer of any agency charged with the enforcement of animal cruelty laws, bank manager, financial manager, or social worker has as a result of his or her appointment, employment, or practice substantial cause to believe that an adult is in need of protective services because of abuse, neglect, or exploitation by another, he or she shall immediately report this belief in accordance with subsection (c) of this section." In addition, "Any person may voluntarily report an alleged case of abuse, neglect, self-neglect, or exploitation when he or she has reason to believe that an adult is in need of protective services" (§7-1903(a)(2)).

Each patient has the right "To be free from mental and physical abuse, neglect, and exploitation by agency employees or contract personnel" (22-B DCMR §3912.2(i)). If the Agency is Medicare-certified, any staff member who identifies, notices, or recognizes mistreatment, neglect, abuse, 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’s rule is simple: every staff member who suspects abuse, neglect, self-neglect, or exploitation of an adult reports it to the Agency at once and makes sure APS is called the same day. Nobody at the Agency may stop, delay, or discourage a report, and no one is disciplined or retaliated against for reporting in good faith as the Agency’s own standard.

Staff are in patients’ homes regularly and are often the first to notice. Watch for:

• Physical: unexplained bruises, burns, fractures, or injuries in different stages of healing; injuries the explanation does not fit; restraint marks; fear of a caregiver.
• Neglect: poor hygiene, untreated wounds or pressure injuries, dehydration, weight loss, missing medications, lack of heat, food, or working utilities, a dependent patient left alone.
• Exploitation: missing money, cards, valuables, or medications; unpaid bills or utility shut-off notices despite enough income; new "friends" or relatives controlling finances; sudden changes to a will, deed, or bank account; pressure to sign documents.
• Psychological: threats, insults, isolation from friends or family, a caregiver who will not let the patient speak alone with staff.
• Self-neglect: a patient who, because of physical or mental impairment, cannot keep himself or herself fed, clean, safe, housed, or medically cared for, or cannot manage money, and has no one helping.

If the patient is in immediate danger, call 911 first. Stay with the patient if it is safe, or leave and call from a safe place if you are at risk. Give first aid within your training. Do not confront the suspected abuser, investigate yourself, or promise the patient that you will keep the matter secret. Preserve evidence: do not clean up or move things unless needed for safety.

Nurses, therapists, social workers, the supervising nurse, and the Director are mandatory reporters when they have substantial cause to believe an adult needs protective services because of abuse, neglect, or exploitation by another (§7-1903(a)(1)). Aides and other staff may report directly to APS at any time (§7-1903(a)(2)), and under this policy every staff member who suspects abuse, neglect, self-neglect, or exploitation must make sure APS is told: either by calling APS directly or by telling the supervising nurse or Director, who calls APS at once. If you tell a supervisor and do not see the report made the same day, call APS yourself.

Report immediately: as soon as the patient is safe, and in any case the same day. Call the APS hotline, (202) 541-3950, which is available 24 hours a day, 7 days a week. A report "may be either oral or written" (§7-1903(c)). Self-neglect is reported when the patient is at serious risk and the care team cannot reduce the risk with the patient’s agreement; the supervising nurse makes that decision with the reporter the same day.

Under §7-1903(c), each report includes, if known: the name, age, physical description, and location of the adult; the name and location of the person or persons allegedly responsible; the nature and extent of the abuse, neglect, self-neglect, or exploitation; the basis of your knowledge; and any other information that might help an investigation. Mandatory reporters may be required to identify themselves (§7-1903(c)). Disclosing this information to APS is permitted by HIPAA (45 CFR §164.512(c)).

The mandatory duty does not apply to a social worker or licensed health professional who has as a client or patient the person allegedly responsible for the abuse or neglect (§7-1903(b)). In that case the Agency still makes the report through another staff member or the Director.

• Tell the supervising nurse, Robin Sample, RN, or the on-call nurse by phone at once, and complete Form DC-HH-SG-01-A and an incident report (Policy DC-HH-QA-02) before the end of the shift.
• The supervising nurse makes sure APS has been called, notifies the Director, updates the plan of care for the patient’s safety (for example, more frequent visits, a change of caregiver, or help arranging another living situation), and tells the patient’s physician.
• If an Agency staff member or contractor is suspected, the Director starts Policy DC-HH-SG-03 at once, including removing that person from patient contact.
• If a crime may have occurred, the Director makes sure the police are informed.

• If a report alleges an immediate, substantial risk of life-threatening harm, APS immediately notifies the police, and an APS worker begins an investigation within 24 hours of receiving the report (D.C. Code §7-1904(a)(3)). For other reports, an APS worker begins within 10 days, excluding Saturdays, Sundays, and legal holidays (§7-1904(a)(4)).
• APS must secure the adult’s consent before entering the home or approaching the adult; an adult who objects can end the investigation unless the objection appears prompted by fear or intimidation or the adult is incapacitated (§7-1904(b)). Staff respect the patient’s choices while continuing to offer help.
• Staff cooperate with APS investigators, share relevant information, and keep giving care unless it is unsafe to do so.
• Information about who made a report is protected; anyone holding a report must take reasonable steps not to reveal the reporter’s identity to the person allegedly responsible (§7-1903(d)(3)).

If the Agency is enrolled with DC Medicaid as an EPD Waiver provider:

• Abuse, neglect or abandonment, and exploitation are serious reportable incidents (29 DCMR §4254.4). DHCF is notified within 24 hours or the next business day, and every SRI "involving death, neglect, abuse, and theft of consumer personal property occurring at a beneficiary's natural home" is reported "to Adult Protective Services and DHCF" (§4254.6(a), (d); Policy DC-HH-QA-02).
• Each beneficiary is informed "upon initial enrollment and on an annual basis thereafter, on the recognition and prevention of abuse, neglect, and exploitation, including how to safely report concerns" (§4222.11(c)). The Agency gives this teaching at admission and at a visit each year and records it in the record.

If the Agency is enrolled with DC Medicaid for personal care aide services, each beneficiary has the right "To be free from mental and physical abuse, neglect and exploitation from persons providing services" (29 DCMR §5014.3(g)).

Accountability under this policy is allocated as follows.

Form DC-HH-SG-01-A and the incident report are kept with the incident records (Policy DC-HH-QA-02) for at least ten years as the Agency’s own standard and, for EPD Waiver beneficiaries, for at least ten years or until any investigation ends, whichever is longer (29 DCMR §4254.8). The clinical record contains the facts observed and the care given, not the report itself. Each quarter the QAPI committee reviews the number of reports and their timeliness (Policy DC-HH-QA-01).

Every staff member is trained at orientation and every year on the signs of abuse, neglect, self-neglect, and exploitation, the APS hotline, what to report, and that they must report even if unsure. The APS hotline number is on staff ID cards or the mobile app and posted in the office as the Agency’s own standard.

This policy implements the following authorities.

• D.C. Code §7-1901 (definitions); §7-1903 (reporting); §7-1904 (investigations).
• 22-B DCMR §3912.2(i) (freedom from abuse, neglect, and exploitation); §3905.2(i).
• 29 DCMR §5014.3(g) (personal care aide services) and §4222.11(c), §4254.4, §4254.6, §4254.8 (EPD Waiver), if the Agency is enrolled.
• 42 CFR §484.50(e)(2), if the Agency is Medicare-certified; 45 CFR §164.512(c).

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 14 is amended, the amendment is recorded in this table and a new version of this policy is issued.