Protection from Harm Abuse, Neglect, and Exploitation

Transcription

1 POLICY: PURPOSE: State Supported Living Centers Statewide Policy & Procedures Policy Number: 01. Effective: xx/xx/xxxx Replaces: 01.1 Protection from Harm Abuse, Neglect, and Exploitation The purpose of this policy is to establish procedures for the identification, reporting, trending, analysis, and prevention of abuse, neglect, and exploitation (ANE) at State Centers. Any event or situation which has harmed or may potentially harm a resident must be immediately identified, reported, reviewed, investigated, and corrected, as specified by the procedures herein. APPROVED BY: Chris Adams Assistant Commissioner State Supported Living Centers APPLIES TO: State Center employees, volunteers and contractors DISTRIBUTION: The State Center must ensure the policy, all exhibits, and forms are distributed to applicable staff, contractors, agents and to any resident or LAR requesting a copy. CONTACT: Policy/Rules Coordinator (1) -1 EXHIBITS AND FORMS: Exhibits Exhibit A: Guidelines for Securing Evidence Exhibit B: Unusual Incident Codes and Reporting Matrix Exhibit C: Procedures in ANE Investigations and Thurston Rebuttal Proceedings Exhibit D: Reasonable Suspicion of a Crime Against a Resident Exhibit E: ANE Resource Guide Forms AN-1-A Client Abuse and Neglect Report DADS 0 Staff Acknowledgement of Reporting ANE SSLC 00B High Profile Incident Report REFERENCES: Settlement Agreement, Section D 0 Texas Administrative Code (TAC), Chapter, Subchapters A-D 0 TAC, Part 1, Chapter ; DFPS Definitions and Classifications of ANE Texas Civil Practice and Remedies Code, and 1.00 Memorandum of Understanding (MOU) Reportable Incidents MOU Mandatory Reporting of Physician Misconduct/ Malpractice MOU ANE Investigations Federal Survey & Certification Letter (S&C) #-1 and #-0; Provider Letter (PL) #1-0; PL #0-0, PL #-1 Page 1 of

2 Definitions to be added to dictionary Advanced Practice Nurse (APN): A registered nurse approved by the Texas Board of Nursing to practice as an advanced practice nurse on the basis of completion of an advanced educational program. The term includes a nurse practitioner, nurse midwife, nurse anesthetist, and clinical nurse specialist. The term is synonymous with advanced nurse practitioner. Agent: Any person not employed by the State Center but working under the auspices of the State Center (e.g., a volunteer, a student). Alleged Perpetrator (AP): A person alleged to have committed an act of abuse, neglect, or exploitation (ANE). Competency-based training: The provision of knowledge and skills sufficient to enable the trained person to meet specified standards of performance as validated through that person s demonstration that he or she can use such knowledge or skills effectively in the circumstances for which they are required. Department of Family And Protective Services (DFPS) Investigator: An employee of DFPS with expertise and demonstrated competence in conducting investigations who has received training on techniques for communicating effectively with individuals with a disability. Designee: A staff member who is immediately available and who is temporarily or permanently appointed to assume designated responsibilities. Immediately: As soon as possible but no later than one hour of discovery, witness, or learning of an incident. Incite: To spur to action or instigate into activity; implies responsibility for initiating another's actions. Medical Intervention: Treatment by a licensed medical doctor, osteopath, podiatrist, dentist, physician assistant, or advanced practice nurse in accordance with generally accepted clinical practice. Non-Serious Physical Injury: Any injury requiring minor first aid and determined not to be serious by a registered nurse, advanced practice nurse, physician assistant, or physician. Notification: Formal announcement to a designated third party. Office of Independent Ombudsman (OIO): Established for the purpose of investigating, evaluating, and securing the rights of residents of State Centers. Perpetrator Unknown: Term used by DFPS to indicate that ANE occurred but positive identification of the responsible person(s) cannot be made. Page of

3 Prevention and Management of Aggressive Behavior (PMAB): The Health and Human Service Commission s proprietary risk management program that uses the least intrusive, most effective options to reduce the risk of injury for residents and for staff from acts or potential acts of aggression. Primary Care Provider (PCP): A physician, advanced practice nurse, or physician assistant who provides primary care to a defined population of patients. The PCP is involved in health promotion, disease prevention, health maintenance, and diagnosis and treatment of acute and chronic illnesses. Review Authority: An established group of people who conduct a review of all final DFPS reports, and must include designated staff members. The Review Authority reviews the final DFPS reports and makes recommendations to the director/designee for review and approval. This typically includes the Incident Management Coordinator, unit director, and investigator. Root Cause Analysis: A process of identifying the basic or causal factors of how an incident occurred, through analysis and asking questions such as why or what contributed to this event. The intended outcome of this process is to identify variations in performance or precipitating variables that could be eliminated and thereby prevent future occurrences. Serious Physical Injury: Any injury requiring medical intervention or hospitalization or any injury determined to be serious by a physician or advanced practice nurse (APN). Medical intervention is treatment by a licensed medical doctor, osteopath, podiatrist, dentist, physician's assistant, or APN. Medical intervention does not include first aid, an examination, diagnostics (e.g., x-ray, blood test), or the prescribing of oral or topical medication. (0 TAC, Part 1,.()) Sexual exploitation: A coercive or manipulative pattern, practice, or scheme of conduct by an employee, contractor, or agent. The act may include sexual contact that can reasonably be construed as being for the purposes of sexual arousal or gratification or sexual abuse of any resident. Sexual exploitation does not include obtaining information about an resident s sexual history within standard accepted clinical practice. Systems issue: Term used by DFPS to indicate that the lack of established policy or procedure contributed to the confirmed ANE. Page of

4 I. What constitutes ANE? A. Physical abuse: 1. An act or failure to act performed knowingly, recklessly, or intentionally, including incitement to act, which caused or may have caused physical injury or death to a resident;. An act of inappropriate or excessive force or corporal punishment, regardless of whether the act results in a physical injury to a resident; or. The use of restraints on a resident not in compliance with federal and state laws and regulations. (Reference: 0 TAC.) B. Sexual abuse: Any sexual activity, including but not limited to: 1. Kissing, hugging, stroking, or fondling a resident with sexual intent;. Engaging in (or asking, soliciting, or compelling a resident to engage in) sexual conduct (Penal Code,.01) or any activity defined as obscene (Penal Code,.1) with a resident.. In the presence of a resident, engaging in or displaying (or asking, soliciting, or compelling a resident to engage in) any activity that is obscene, as defined in the Texas Penal Code.1;. Committing sexual exploitation (0 TAC.1) against a resident;. Committing sexual assault (Penal Code.0) or aggravated sexual assault (Penal Code.01) against a resident;. Causing, permitting, encouraging, engaging in, or allowing the photographing, filming, videotaping, or depicting of a resident if the employee, agent, or contractor knew or should have known that the resulting photograph, film, videotape, or depiction of the resident is obscene (Penal Code,.1) or is pornographic. (Reference: 0 TAC.1) C. Verbal/emotional abuse: Any act or use of verbal or other communication, including gestures, to curse, vilify, or degrade a resident or threaten a resident with physical or emotional harm. The act or communication must result in observable distress or harm to the resident or be of such a serious nature that a reasonable person would consider it harmful or causing distress. (Reference: 0 TAC.1) D. Neglect: A negligent act or omission by any person responsible for providing services to a resident, which caused or may have caused physical or emotional injury or death to the resident or which placed him or her at risk of physical or emotional injury or death. Neglect includes, but is not limited to, the failure to: 1. Establish or carry out an appropriate individual program plan or treatment plan for an resident, if such failure results in a specific incident or allegation involving the resident;. Provide adequate nutrition, clothing, or health care to a specific resident; or. Provide a safe environment for a specific resident, including the failure to maintain adequate numbers of appropriately trained staff, if such failure results in a specific Page of

5 incident or allegation involving the resident. (Reference: 0 TAC.1) E. Exploitation: The illegal or improper act or process of using a resident or his or her resources for monetary or personal benefit, profit, or gain. (Reference: 0 TAC.1) F. ANE does not include: 1. The proper use of restraints or positive behavior support plans in accordance with federal and state laws and regulation and department and facility policies and the Settlement Agreement;. Other actions taken in accordance with State Center rules;. Actions that the employee, agent, volunteer, or contractor may reasonably believe to be immediately necessary to avoid imminent harm to self, residents, or others IF such actions are limited only to those actions reasonably believed to be necessary under the existing circumstances and the actions do not include acts of unnecessary force or the inappropriate use of restraints or positive behavior support plans; or. General complaints (e.g., regarding rights violations; theft of property; the daily administrative operations of a facility). (Reference: 0 TAC.) II. State Center Expectations State Centers must ensure consistent and effective implementation of this policy by: 1. Demonstrating a commitment of zero tolerance for ANE;. Training staff in identifying, reporting, and preventing ANE;. Requiring staff to report allegations of ANE and reasonable suspicion of a crime against a resident;. Ensuring the safety and protection of residents involved in allegations;. Ensuring that the environment is safe, secure, and responsive to the emotional needs of residents who have experienced trauma from ANE;. Reviewing the criminal history, as well as factors such as a history of perpetrated ANE as revealed through checks of the Employee Misconduct Registry and Nurse Aide Registry, before permitting a staff person or volunteer (volunteers on more than five occasions within one calendar year) to work directly with any resident and annually thereafter. State Center staff must directly supervise volunteers for whom an investigation has not been completed when they are working directly with residents living at the State Center. The State Center must ensure that the investigation indicates that the staff person or volunteer would pose no risk of harm to a resident before permitting the staff person or volunteer to work directly with residents;. Dismissing an employee or volunteer whose criminal history or registry check reveals an offense that constitutes a bar to employment or volunteer status;. Posting and supplying information on resident rights in a visibly, accessible area on each living unit and day program site, with a brief and easily understood statement of residents rights, including information about how to exercise such rights and how to report rights Page of

6 violations or report ANE allegations to the director, Human Rights Officer, DADS Consumer Rights and Services, the Office of Independent Ombudsman, and DFPS;. Posting a notice specifying the right of employees to be free from retaliation for reporting a reasonable suspicion of crime against a resident and how employees may file a complaint if retaliated against;. Facilitating DFPS investigations of allegations;. Facilitating peer review of allegations involving clinical practice; 1. Notifying appropriate authorities and other persons regarding issues relating to an allegation; 1. Immediately removing alleged perpetrators; 1. Ensuring that an assigned investigator is not in the direct line of supervision of the alleged perpetrator; 1. Ensuring that any employee or agent of the State Center, resident, family member, LAR, or visitor who reports ANE is not subject to retaliation; 1. Ensuring that appropriate disciplinary action is taken against any employee or agent found to have engaged in retaliation, up to and including termination; 1. Ensuring proper personnel disciplinary action is taken in response to confirmed allegations of ANE; 1. Ensuring local policy lists activities considered to be crimes by the local law enforcement agency of jurisdiction and specifies procedures for referring, as appropriate, allegations of abuse and/or neglect to local law enforcement; and 1. Maintaining and providing a resource guide on recognizing and reporting signs of ANE of residents to the residents, their primary correspondents, and their LARs. The resource guide is provided to all new residents upon admission, and annually to the resident, LAR, and primary contact (Exhibit E: ANE Resource Guide). III. Staff Training A. All staff must complete competency-based training on preventing and reporting abuse and neglect (ABU00) during pre-service and every 1 months, thereafter. All required training must be appropriately documented by certification and date of completion. Supervisors will periodically assess employee knowledge and provide additional training as needed. B. All staff must sign a statement acknowledging zero tolerance for ANE of residents and the obligations for reporting any suspected ANE and reasonable suspicion of crime against a resident (see DADS Form 0) during pre-service and every 1 months thereafter. Each State Center must maintain copies of these signed forms. C. All staff who investigate abuse and neglect allegations will receive training in working with persons with intellectual disabilities. IV. Protections for Residents A. Discovery or Witness The employee, agent, contractor, or volunteer who discovers or learns about ANE must: Page of

7 Immediately take necessary action to stop the ANE;. Arrange for nursing and/or medical examination, as necessary (e.g., when the alleged incident resulted in or could have resulted in injury);. Comfort and reassure the victim(s);. Take appropriate steps to preserve and/or secure physical evidence related to an allegation, if any (i.e., take precautionary measures to prevent physical evidence from being destroyed, stolen, tampered with, etc.);. Immediately call DFPS and the director/designee to report ANE; and. Document on a Client Injury Report (CIR) form if any injury is suspected or could have occurred as a result of the alleged action/inaction. B. Injury or Possible Injury 1. Staff must initiate necessary first aid to address the injury as soon as they discover or witness an injury.. Staff who witnessed/discovered the injury must document its occurrence and relevant facts about it in the Description of Incident section of the Client Injury Report (CIR).. Staff must notify a licensed nurse. A licensed nurse must complete an initial examination of the resident immediately but no later than one hour. The licensed nurse documents the results of this examination in the Description of Injury and appropriate parts of the Examination/Assessment/Treatment sections of the CIR. (See Policy #00, Incident Management; Exhibit C, Client Injury Reporting Procedures.) The examination and treatment of abuse or neglect-related injuries is documented on the Client Injury Report, with a copy submitted to the DFPS investigator. C. Physical Evidence 1. If physical evidence is present, the initial reporter and the facility investigator(s) must take steps to preserve and secure the physical evidence. (See Exhibit A, Guidelines for Securing Evidence.). The facility investigator should prioritize the collection of evidence that is most at risk of contamination. In most cases, the highest priority will be to identify interviewees and physically separate them until they have been interviewed. D. Environmental Hazards 1. If the incident creates a hazard to the environment or to residents, the hazard must be cleared or residents removed from the area to ensure safety.. The investigator should secure the evidence and take photographs before clearing the hazard. E. Photographs 1. In cases of injury and in other cases as deemed appropriate, the investigator may take photographs within hours of discovery/witness.. The investigator always informs the resident being photographed about the purpose of the photographs as a central element of an investigation to ensure protection of health and safety.. If the resident objects or shows displeasure with the request, the investigator must determine if the photographs are absolutely necessary to the investigation. If so, the Page of

8 investigator takes the photographs and notes in the investigation notes that they were taken without the resident s permission.. Each photograph must be labeled with the following information: a. The date and time the photograph was taken; b. A brief description of the photograph and what it depicts; c. The name of the resident photographed; and d. The name of the person taking the photograph. F. Sexual Abuse or Sexual Exploitation 1. Staff who witness or observe an incident that may constitute sexual abuse or sexual exploitation must: a. Ensure the activity is stopped with the least amount of verbal or physical intervention necessary. Staff must respect the personal dignity of the resident(s) involved and treat the situation with utmost sensitivity. Under no circumstances must the involved resident(s) be subjected to punitive action. Staff must remain calm. b. Immediately notify a nurse and/or PCP. PCP/RN must not perform any medical procedure which may destroy any evidence if there is an allegation of sexual abuse. The PCP/RN may follow local rape crisis center procedures for care of any resident when there is an allegation of sexual abuse. c. Immediately call DFPS and the director to report the sexual incident. d. Initiate a Client Injury Report (CIR) if an injury is observed or suspected, noting relevant information about the incident as required on the form. A nurse must complete the CIR.. The State Center Infection Control Practitioner must be notified of the diagnosis of any sexually transmitted disease immediately, if possible, but in no case more than hours later. Documentation of this notification is noted on the Unusual Incident Report (UIR). a. In allegations of sexual exploitation, law enforcement is responsible for notifying the prosecuting attorney in the county in which the alleged sexual exploitation of the resident(s) occurred. Documentation of this notification is noted on the UIR. b. In allegations of sexual exploitation involving an employee, contractor, or agent who is licensed to practice under a state licensure board, the State Center must ensure notification of the allegation is made to the appropriate licensure board. c. If confirmed of sexual abuse (Class I abuse), an employee must be dismissed from employment. G. Emotional Assessment 1. If an unusual incident occurs that involves aggression or threat of security for one or more residents, including but not limited to an allegation of ANE or a serious injury resulting from aggression by a peer, the State Center must take immediate action to ensure the safety and security of affected staff and residents by ensuring that appropriate emotional assessments of all persons involved in or related to the incident are completed and necessary interventions are immediately initiated when a person s safety or security is identified as an issue. a. The assessment must be completed within hours by a psychologist, board certified behavior analyst (BCBA), or staff with specific training in conducting the assessment to determine appropriate follow-up action. Page of

9 b. The assessment must be completed with all residents involved in or affected by the incident. c. The assessment must also include discussion with all relevant staff involved in the incident to ascertain their perception of safety, security, and ability to address any follow-up actions necessary to ensure the continued safety and security of residents, staff, and the environment. d. The results of the assessment and any immediate corrective actions initiated must be documented in the clinical record of each resident assessed (not just the injured party) and a summary must be documented in the UIR to include all immediate actions for both residents and staff.. If issues are identified from the emotional assessment of any resident, immediate action must be initiated to address those issues, provide necessary protection for the resident, and provide specific instructions to staff working directly with the resident to ensure consistent adherence to the immediate corrective actions.. Results of the assessment must be reported to the appropriate administrative duty officer as an element of the unusual incident investigation process. Documentation of this report and any additional immediate follow-up action determined necessary by the administrative duty officer must be entered on the UIR.. Follow-up assessment of the perceptions of safety and security of the residents and staff must be documented at least every hours until the IDT has opportunity to review the incident, along with all relevant issues associated with the incident and the results of the emotional assessment. Documentation of the follow-up must also be included on the UIR.. If a Critical Incident Team (CIT) meeting held, all relevant information and documentation related to the emotional assessment of residents and staff should be fully reviewed by the CIT and documentation of any additional actions determined necessary by the CIT should be incorporated into the UIR.. The IMRT must: a. Review the emotional assessment findings and follow-up action to determine its sufficiency and ensure that all involved residents were provided the assessment, that all immediate and subsequent actions were taken to address the issues from the emotional assessment, and that any identified follow-up actions were consistently carried out until all safety and security concerns were successfully resolved; b. Review all actions taken with staff to ensure that staff are supported in carrying out any actions necessary to protect residents, staff working with the residents, and the environment itself and that these actions continue until the issue is successfully resolved; and c. Document its discussion, recommended actions, and follow-up in the UIR. H. Emotional Security and Restoration 1. General Principles. a. The State Center ensures that environments that promote a sense of security, safety, and emotional well-being are maintained and are responsive to residents and staff who may feel afraid or vulnerable due to abuse, neglect, aggression or other forms of trauma. Staff are trained to recognize these emotions and how to be responsive or request additional supports when emotions of fear or anger can disrupt one s sense of Page of

10 security. Each resident s psychological history and present needs are considered in developing individualized ways to help him or her feel secure. b. Staff are observant of verbal and non-verbal indicators that the resident may be in distress and respond to these indicators, with the intention of restoring the resident s sense of comfort and emotional regulation and avoiding an emotional outburst that might involve peer-to-peer aggression. c. The State Center provide a variety of general approaches and specific interventions to residents who have had a history of trauma or have had more recent experienced trauma, such as peer-to-peer aggression or abuse, neglect, or exploitation.. General Approaches. a. The IDT discusses any history of trauma and other clinical factors to identify better ways to help the resident feel secure and for staff to avoid actions found to cause distress for him or her. b. Staffs are trained on how to: i. Recognize signs of victimization and emotional reactions to trauma and respond to help restore emotional balance; ii. Recognize their own emotions in non-stressful and stressful situations and manage these emotions so that they are more secure and can help the resident feel secure; and iii. Respond to signs of emotional distress and encourage the resident to practice effective coping skills and restoration of emotional balance. c. If the resident wants to learn about ways to communicate his/her feelings, how to recognize and prevent victimization, or adaptive behavior that could replace aggression or loss of temper, one or more clinical or skill acquisition plans may be developed. d. If the resident wants to participate in individual or group psychotherapy to discuss feelings or present or past trauma, the IDT arranges counseling service.. Specific Interventions. In response to an immediate situation in which a resident is a victim of aggression, one or more of the following specific interventions may be implemented to help the person restore emotional balance and a sense of security: a. The resident is encouraged to discuss the incident, including his or her feelings and how staff can provide comfort. b. If the resident prefers, a favorite staff person is allowed time to talk to the resident about the event in a setting that private and comfortable for the resident c. If the resident has favorite activities that help him or her relax in stressful situations, those activities are provided. d. The resident s level of supervision may be adjusted for a time, if he or she expresses concerns about safety. Additional staff (e.g., the unit manager or residential coordinator) may also be asked to visit to ensure that the environment is safe. e. The resident s psychologist/bcba or the psychologist on call must talk the resident as soon possible, but no later than hours after the incident, to discuss the resident s feelings and sense of security, assess any immediate needs, and take action. f. The Director of Psychology/Behavioral Services designates a staff member to talk with those staff present during the incident to discuss their feelings and stress levels and to take action as needed Page of

11 g. The IDT meets within one working day of the incident to review the incident and consider additional action. I. Emergency Restrictive Practice 1. The unit director/designee notifies the resident s QDDP or designee of the incidents that require emergency restrictive protections, i.e., those which require an increase in level of supervision or other restrictive practice.. The QDDP/designee completes an Emergency Restrictive Practice (ERP) form as necessary (SSLC 001F).. The IDT of each resident involved in the alleged incident meets within one working day as needed to determine if the immediate protective restrictive actions are appropriate and whether those actions should continue.. The QDDP completes the Individual Support Plan Addendum (ISPA, SSLC 00D) within one working day of the IDT meeting and sends it to the IMC and investigator so recommendations can be written into the investigative report. The recommendations must minimally include a responsible person and a projected due date for completion. J. Access to the Alleged Victim If the alleged perpetrator is known but is not an employee/agent (e.g., family member, friend, guest), the director/designee imposes a restriction on the alleged perpetrator's access to the alleged victim pending investigation. V. Notification Responsibilities All employees, agents, contractors, and volunteers who suspect or have knowledge of, or who are involved in an allegation of ANE, must comply with the following reporting requirements. Allegations of ANE must be verbally reported immediately to DFPS and the director/designee. A. Incidents Reportable to DFPS 1. Each employee, agent, contractor, or volunteer who suspects or has knowledge that a resident has been abused, neglected, or exploited, including prior to admission, during an absence, or while in residence at the State Center, must make a verbal report to DFPS immediately upon suspicion or after learning of the incident, by calling Reporting ANE through the DFPS website is not acceptable.. It is essential to protect the integrity of the DFPS investigation. If the person making the allegation is not an employee, agent, or contractor (e.g., a guest or visitor), staff will assist the person in making the report, if necessary. The director must: a. Ensure that interviews are limited to providing the alleged victim with protection (rather than investigating the incident); b. DFPS investigators are the first to interview and take statements from witnesses to an incident that has been or should be reported as possible ANE; c. Disclose and discuss information about incidents under DFPS investigation on a need-to-know or qualified privilege basis only, so the investigator will have maximum opportunity to collect uncontaminated evidence; Page of

12 d. Designate a contact staff person to coordinate with the DFPS investigator to ensure private interview space, private telephones, and employees/agents are available to the DFPS investigator; e. Require employees and agents to cooperate with DFPS investigators so that they are afforded immediate access to all records and evidence as necessary to conduct an investigation in a timely manner; f. Ensure employees and agents who are relevant to the investigation are available in an expeditious manner; and g. Ensure that employees who fail to cooperate with an investigation are subject to disciplinary action.. Any pregnancy of a resident, provided there is medical verification that there is reasonable expectation that conception could have occurred while the resident was under the care of the State Center or contractor, or any diagnosis of a sexually transmitted disease for a resident which could have occurred while the resident was under care of the State Center or contractor, must be reported as possible abuse or neglect.. If an aggressive action by a resident (including non-consensual sexual activity between residents) occurs as a result of possible neglect, the action is reported as neglect.. Failure to make reports as required by this section within the allotted time period without sufficient justification is considered a violation of DADS policy and the employee is subject to disciplinary action and possible criminal prosecution. An employee/agent found to have made a false statement of fact, refused to cooperate, or destroyed evidence during an investigation is also subject to disciplinary action. B. Incidents Reportable to DADS Regulatory Services via Consumer Rights and Services 1. The director/ designee must report those allegations that are considered reportable incidents to DADS Regulatory in accordance with the memorandum of understanding between DADS and DFPS governing reportable incidents. If the incident has been concurrently reported to DFPS, the director/designee must provide Consumer Rights and Services with the DFPS Case Reference Number.. Incidents reportable within hours. Consumer Rights and Services has a dedicated tollfree number (1-00--) for reporting incidents. The following incidents meet the requirements for reporting to DADS Regulatory within hours of the incident occurring or being reported: a. Any act or failure to act performed knowingly, recklessly, or intentionally, including incitement to act, which caused or may have caused serious physical injury or death to a resident b. Sexual abuse by a staff to a resident c. Resident-to-resident sexual abuse resulting from coercion, physical force, or taking advantage of the disability of the resident receiving services, and any sexual activity involving a child under 1 years of age d. Any pregnancy of a resident, regardless of the identity of the perpetrator, provided there is medical verification that conception could have occurred while the resident was receiving services at the State Center, community-based service, or community center ICF/IID program or any diagnosis of a sexually transmitted disease in a resident which could have occurred while the resident was receiving services from the State Center or one of its contractors Page 1 of

13 e. Resident-to-resident aggression that results in a serious physical injury f. All deaths g. Any reasonable suspicion of crime against a resident that did not result in serious physical injury to a resident. Incidents reportable within two hours. Per S&C #-0, the facility is responsible for ensuring that any employee, agent, or contractor who has reasonable suspicion that a crime against a resident has occurred must report it to DADS Consumer Rights and Services within two hours if the incident results in serious physical injury to a resident. C. Incidents Reportable to the Office of Independent Ombudsman (OIO) The director/designee provides the OIO with access to all incident reports regarding ANE allegations, including each administrative, clinical, or rights issues referred back to the State Center and each final ANE investigation that the State Center receives from DFPS. D. Incidents reportable to DADS State Office for State Supported Living Centers: 1. High Profile Incidents a. A high profile incident includes but is not limited to the following: i. Death of a resident ii. Determination of immediate jeopardy by DADS Regulatory Services iii. An incident anticipated to result in media or legislative inquiry iv. An arrest or detainment of a resident by law enforcement v. An allegation of Class I abuse of a resident vi. Unauthorized departure of a resident on or off campus if the resident has been missing for more than one hour or more quickly during extreme weather conditions vii. Any serious physical injury resulting from peer-to-peer aggression for which notification to DADS Consumer Rights and Services occurred viii. Any incident determined significant by the director/designee b. During business hours, the director/designee provides a verbal report of the high profile incident to the State Office Incident Management Coordinator by telephone. If unable to reach the Incident Management Coordinator, the director/designee notifies the administrative assistant who will ensure contact with the appropriate designee. Voice mail messages are not permissible to satisfy this reporting requirement. c. Outside business hours, the director/designee verbally reports a high profile incident to the State Office On-Call Designee using the on-call number. If the call is not immediately answered, the director/designee should proceed with calling the following staff in this order: State Office Incident Management Coordinator, Director of Operations, and Assistant Commissioner. d. After making the verbal report, the director/designee sends an describing the incident and providing relevant details of its occurrence to the Assistant Commissioner, Director of Operations, State Office Incident Management Coordinator, and State Office On-Call Designee within the timeframes set out for the specific type of incident in the Unusual Incident Report Coding and Reporting Matrix. The content of will follow the guidelines in the High Profile Incident Report template (SSLC 00B). Page 1 of

14 e. If, due to the severity, intensity, or nature of the incident or situation, it is not possible within the specified timeframe to provide a full, thorough, and accurate summary describing the incident and impact, the director/designee provides a brief description and indicates when additional information will follow.. Non-High Profile Unusual Incidents a. The director/designee ensures non-high profile unusual incidents are reported through the daily incident summary that includes both high profile and non-high profile unusual incidents. b. The daily summary of all unusual incidents is sent via to the State Office Incident Management Coordinator no later than :00 a.m. on the each working day. c. The State Office Incident Management Coordinator reviews the summary, revises as deemed appropriate, and forwards the summary via to the following persons by the close of business each working day: i. Assistant Commissioner ii. State Office Director of Operations iii. Deputy Commissioner iv. Director of the Center for Consumer and External Affairs v. Media Relations Coordinator vi. Director of Government Relations E. Incidents Reportable to Law Enforcement 1. If a resident is alleged to be the victim of a crime, including but not limited to theft, vandalism, assault, etc., the facility must ensure that the crime is reported to local law enforcement within required timeframes.. Reports regarding alleged "sexual exploitation" committed by a "mental health services provider" (as defined in the Texas Civil Practice and Remedies Code, 1.001) are made by the director/designee to the prosecuting attorney in the county in which the alleged sexual exploitation occurred and any state licensing board that has responsibility for the mental health services provider's licensing in accordance with the Texas Civil Practice and Remedies Code, F. Incidents Reportable to the Alleged Victim & His or Her LAR/Primary Contact 1. Within hours after notification of an allegation of ANE, the director/designee notifies the alleged victim (if appropriate) and the alleged victim's LAR or primary contact.. If unable to notify the LAR or primary contact within hours, the director/designee provides notification by certified letter with a return receipt requested. The LAR/primary contact must also be notified of the disposition of the incident after the investigation is complete.. The director must notify the alleged victim or LAR of the right to receive a copy of the investigative report. VI. State Center Investigations A. Immediately upon notification of an unusual incident, the director/designee notifies the Incident Management Coordinator (IMC) and/or the facility investigator. Page 1 of

15 B. The facility investigator initiates a preliminary and limited investigation immediately upon receiving either a verbal or written report of an allegation of ANE. This preliminary investigation should only include: 1. Ensuring the resident is protected and receiving treatment for any injuries, if necessary;. Securing relevant documentation as soon as possible; and. Efforts to reduce the potential for contamination of information for the investigation. C. Within four hours of intake: 1. The State Center must provide DFPS the following: a. Verification that the alleged victim named in the intake receives services at the facility; b. Whether the resident has an injury and its severity; c. Whether the resident has been seen by medical staff; d. That injuries have been treated; e. Whether the resident is currently showing signs of distress as determined by the emotional assessment described in IV.G above; f. Whether the resident needs accommodations in order to communicate with the investigator; g. Whether a sexual assault exam was completed and by whom; and h. For allegations of sexual abuse, whether the victim has showered.. DFPS will direct the facility to: a. Protect any physical evidence for APS or law enforcement such as blood, clothes, or damage to the unit or room that was part of the incident; b. Obtain photographs of any physical evidence that may not be available at the time of an on-site visit; c. Re-assign the alleged perpetrator so he or she does not have contact with residents; and d. Protect the resident and the evidence. D. Within hours of intake, the State Center must provide DFPS with the following documentation or information: 1. Client Injury Report. Physical Nutritional Management Plan (PNMP). Positive Behavior Support Plan. Progress notes. Observation notes. Level of supervision sheet. Shift logs. Any other information/documentation pertinent to the particular case E. Witness statements are taken by DFPS when abuse or neglect is alleged or at the point in an internal investigation when abuse or neglect is first suspected. F. The facility investigator is responsible for conducting and documenting unusual incident investigations, including ANE, using the Unusual Incident Report (UIR) format (see Policy #00, Incident Management, for details). Page 1 of

16 G. The facility investigator should prioritize the collection of evidence that is most at risk of contamination. In some cases, securing physical evidence will be necessary and should be initiated first. In most cases (because of the lack of physical evidence), interviewees should be separated and identified as the highest priority for the DFPS investigator. H. The facility investigator is responsible for completing a summary of the investigation to date (five-day status report) and sending reportable incidents to DADS Regulatory within five working days. I. Upon notification from DFPS of a report involving staff that does not constitute ANE, but may constitute an administrative issue, clinical issue, and/or a violation of a resident s rights, the State Center must take necessary and appropriate action to successfully resolve the administrative, clinical, or rights issues. VII. Review of DFPS Final Investigation Report The State Center must conduct a review of all final DFPS reports and must include designated staff members. The Review Authority reviews the DFPS report, makes recommendations, and submits recommendations to the director/designee within two working days for review and approval. Confidentiality of these reports is essential. The State Center must ensure the following processes occur once the report of investigation is received from DFPS: A. The State Center should continue its investigation if the DFPS report is not conclusive. B. The Review Authority may consult with the DFPS investigator about the case. C. If the Review Authority determines that there is cause, it may ask DFPS to reopen the case based on criteria in the Texas Administrative Code. D. The director/designee reviews all reports and may interview witnesses. E. A confirmed finding may not be changed by the director/designee. However if the director/designee disagrees with the DFPS finding of unconfirmed, inconclusive, or unfounded, the director/designee may change the finding to confirmed. F. The director/designee may disagree with the DFPS findings and may: 1. Contest the finding by requesting a review in accordance with 0 TAC, Chapter, Subchapter K, within 0 calendar days from the day the report was signed and dated by the investigator;. Request a OIG Comparison Review when the facility has received findings from OIG, where OIG has sustained a finding when DFPS did not confirm, or investigate the allegation; and/or. Contest the review by apprising the DADS Assistant Commissioner of State Supported Living Centers, who consults with the DADS Commissioner for further review and Page 1 of

17 directives. The decision of the DADS Commissioner and the DFPS Commissioner may not be contested. G. The final disposition is the last uncontested finding, which may be: 1. The DFPS investigator's finding;. The director s/designee's confirmed finding;. The DFPS finding in accordance with Subsection E of this section; or. The DADS Commissioner s and the DFPS Commissioner s decision. H. Within 0 calendar days of receipt of the investigative report or the final finding, the director/designee is responsible for completing the Client Abuse and Neglect Report (AN-1- A) form and ensuring the information is entered into the Client Abuse and Neglect Reporting System (CANRS). I. The director/designee establishes a mechanism for evaluating any recommendations concerning problematic patterns or trends identified during the investigation by the DFPS investigator and the review authority, if applicable. J. All recommendations and concerns documented in a DFPS administrative referral or investigation report must be reviewed and addressed by the director/designee within five working days. Documentation of the recommendations and actions taken must be documented and maintained in the UIR file. K. The State Center ensures the alleged victim or LAR and perpetrator receives proper notification, including findings and appeal methods. L. The director/designee must submit all DFPS administrative referrals to the State Center to the State Office Incident Management Coordinator and Director of Operations within five working days of receipt. VIII. State Center Final Investigation Report A. The State Center is responsible for completion of the UIR when DFPS provides the final ANE investigation report to the State Center. The State Center must reach final conclusions and the report must be reviewed and approved by the director/designee within five working days after receiving the final DFPS report unless there are extraordinary circumstances and the director grants a written extension. B. The final investigation report must provide a clear basis for conclusions. It is completed on a separate UIR from the preliminary investigation report and must contain all relevant information in all sections. The final investigation report must explicitly include: a. The names of all witnesses; b. The names of all alleged victims and alleged perpetrators; c. The names, dates, and times of all persons interviewed during the investigation; d. For each person interviewed, an accurate summary of topics discussed; Page 1 of

18 e. A recording of the witness interview or summary of the questions posed and a summary of material statements made; f. All documents reviewed during the investigation; g. All sources of evidence considered, including previous investigations of serious incidents involving the alleged victim(s) and alleged perpetrators(s) known to the investigating agency; h. The facility investigator's analysis of findings and conclusions, including: i. the resolution of identified discrepancies in the accounts and information obtained; ii. the proximate cause of the incident and the most obvious reason that the incident occurred based on the chronologies, incident history, and psychiatric/behavioral history; and iii. identifying contributing factors to the incident s occurrence and any reason that increases risk or contributes to the probability of the incident s reoccurrence; and i. Recommendations for each concern identified in the report that are concise and stated in objective and measurable terms, with responsibility for the stated outcome given to a specific employee and an expected completion date for achievement. C. The State Center must submit the final investigation report to the State Office Incident Management Coordinator for all unusual incidents. D. The IMC or designee must send a copy of the final investigation report recommendations and concerns to the resident s unit director or designee and the appropriate discipline director to ensure implementation of any corrective action plans. E. The IMC must coordinate all recommendations and remedial actions identified in a final investigation report, root cause analysis report, or final DFPS report. For additional details on IMC responsibilities, please see Policy #00, Incident Management. IX. DADS Regulatory Report A. Within five working days from the date of the initial report of ANE, the following must be sent to DADS Regulatory: 1. For incidents investigated by DFPS, the final investigation report received from DFPS; or. If the final DFPS report is not complete within five working days, a copy of the DFPS interim status report denoting status of the investigation at the five-day interval with the State Center s local report verifying that the five-day status report from DFPS has been reviewed. B. If the DFPS investigation report is not received within calendar days, the State Center submits an extension request form to DADS Regulatory noting that the report has been delayed from DFPS and projecting an expected date of submission for the final report. X. Prohibition Against Retaliation Page 1 of

19 A. Any action intended to inflict emotional or physical harm or inconvenience on a person that is taken because the person has reported ANE or reasonable suspicion of crime against a resident is prohibited. This includes, but is not limited to, harassment, disciplinary measures, discrimination, reprimand, threat, or criticism. The State Center may not retaliate against an employee. B. Any employee or agent or any person affiliated with an employee or agent is prohibited from retaliating against: 1. A resident,. A family member of a resident,. The resident s LAR,. The primary contact of a resident, or. An employee or agent who in good faith reports an allegation. C Any employee or agent found to have engaged in retaliatory action is subject to disciplinary action, up to and including termination. D. A person who believes he or she has been subjected to retaliation as a result of reporting an allegation, or who believes an allegation has been ignored, may contact the director of the facility where the alleged ANE or reasonable suspicion of crime occurred or DADS State Office. E. An employee who believes he or she has been subject to disciplinary action or termination as a result of reporting an allegation of ANE or a reasonable suspicion of crime against a resident may also contact: 1. The Office of the Attorney General at (1) -1 (Consumer Protection Division), if he or she has been subject to adverse personnel action in violation of Government Code, Chapter ; or. The Office of Inspector General at XI. Temporary Work Duty Assignments for Alleged Perpetrators (AP) Staff with an allegation of ANE made against them must be placed on temporary work duty reassignment. In order to expedite the closure of an investigation of a suspected ANE and to ensure an AP's ability to return to work as soon as possible, staff placed on temporary work duty assignment due to an allegation of ANE must follow the steps outlined below to ensure that they are available to meet with the investigator(s) when notified. When DFPS has identified an allegation from a resident who makes frequent false allegations, the director/designee may reassign the AP to work in another location serving other residents. Each State Center must implement a system to ensure that the following temporary work duty assignment activities are followed for ANE investigations: Page 1 of