3195 Neil Armstrong Blvd. Eagan, MN 55121 651-686-0405 204 Mississippi Ave. Red Wing, MN 55066 651-388-7108 224 Main Street Zumbrota, MN 55992 507-732-7888 1202 Beaudry Blvd Hudson, WI 54016 715-410-4216 Revised 01/23/14 Revised 01/19/2009 Vulnerable Adult or Minors Maltreatment Policy and Procedure I-78-D For Reporting Abuse: Call the COMMON ENTRY POINT at 651-385-3232 Vulnerable Adult or Minors Maltreatment Policy/Procedure for reporting incidents of Vulnerable Adult Maltreatment or Maltreatment of Minors I-78 Plan is a description of ProAct Eagan/Hudson And Red Wing/Zumbrota Vulnerable Adult or Minors Maltreatment Plan The ProAct, Inc. Vulnerable Adult or Minors Maltreatment Prevention Plan Is annually presented to the ProAct, Inc. Board of Directors for Approval
WHO MUST REPORT... 3 WHEN ARE REPORTS NOT REQUIRED TO THE COMMON ENTRY POINT... 3 WHEN ARE REPORTS REQUIRED TO THE COMMON ENTRY POINT... 4-5 WHAT DOCUMENTATION MUST BE MAINTAINED BY THE FACILITY... 5-6 RECORD KEEPING... 6 INTERNAL REVIEW... 6-7 CORRECTIVE ACTION PLAN... 7 PROTECTION... 8 DEFINITIONS... 8-14 1. Serious Maltreatment... 8 2. Abuse... 9-10 3. Accident... 10 4. Financial Exploitation... 11 5. Immediately... 11 6. Incident... 12 7. Neglect... 12-13 8. Therapeutic Conduct... 14 Page 2 of 14
WHO MUST REPORT? A mandated reporter is a person who has reason to believe that a vulnerable adult or minor is being or has been maltreated, or who has knowledge that a vulnerable adult or minor has sustained a physical injury which is not reasonably explained. A vulnerable adult or minor is a person who because of physical or mental disability or dependency on institutional services, is particularly vulnerable to maltreatment. A "Mandated Reporter" means a professional or professional's delegate while engaged in: 1) social services; 2) law enforcement; 3) education: 4) the care of vulnerable adults or minors; 5) any of the occupations referred to in section 214.01, subdivision 2; 6) an employee of a rehabilitation facility certified by the commissioner of jobs and training for vocational rehabilitation; 7) an employee or person providing services in a facility as defined in subdivision 6; or 8) a person that performs the duties of the medical examiner or coroner. Every employee of ProAct, Inc. is required to report all observed or suspected maltreatment of a person served, and thus is considered to be a "Mandated Reporter". All persons served by ProAct, Inc. are "categorical vulnerable adults/minors". Reports shall be made immediately (within 24 hours) orally by telephone or otherwise, to the Common Entry Point, (in Goodhue County this is the intake worker at the Goodhue County Social Services office, which is open Monday-Friday 8:00-4:30, 385-3232; after hours: Sheriff s Department: 385-3155; Wabasha County: 651-565-3361. WHEN ARE REPORTS NOT REQUIRED TO THE COMMON ENTRY POINT? Reports are not required to be made if one of the following conditions exists: 1. There is a circumstance where federal laws prohibit the disclosure of chemical dependency patient identifying information without the consent of the person or the person s legal representative. In these situations, the facility and/or the mandated reporter must immediately seek consent to make a report and document the outcome. 2. There is verbal or physical aggression which occurs between patients/residents/clients of a facility, or self-abusive behaviors by these persons, UNLESS the behavior causes serious harm. Documentation of these incidents of aggression and/or self-abusive behavior must be maintained for review by licensing agencies and county adult protection agencies. 3. The circumstance is an "accident" as defined in Minnesota Statutes, section 626.5572, subdivision Documentation of how the individual or facility has determined that the incident meets the definition of accident must be maintained for review by licensing agencies and county adult protection agencies. Page 3 of 14
WHEN ARE REPORTS REQUIRED TO THE COMMON ENTRY POINT? 1. There is a circumstance which is identified as an error in the provision of therapeutic conduct. If an incident is reported in which it is believed that an individual has made an error in the provision of therapeutic conduct to a vulnerable adult or minor, the facility must document how the following criteria are met: A. the incident did not result in injury or harm which reasonably required medical or mental health care; B. the incident did result in injury or harm, which reasonably required medical or mental health care; (i). the necessary care is provided in a timely fashion or dictated by the condition of the vulnerable adult or minor; (ii) if after receiving care, the health status of the vulnerable adult or minor can be reasonably expected, as determined by the attending physician, to be restored to the vulnerable adult s or minor s preexisting condition; (iii) the error is not part of a pattern of errors by the individual C. the incident was immediately reported (as required under section 626.557) internally by the employee or person providing services in the facility; and D. if in a facility, the facility identifies and takes corrective action and implements measures designed to reduce the risk of further occurrence of this error and similar errors; E. the incident was sufficiently documented for review and evaluation by the facility and any applicable licensing, certification, and ombudsman agency Or, reports may be made directly to the Director, Programs & Services or President by completing ProAct, Inc.'s Accident/Incident Report Form (R-107-DTH) detailing the incident and submitting the report to the Director of Programs & Services before the end of the day. 1. The Incident Report shall specify: A. The name and location of the person and the program. B. The nature of the suspected or observed maltreatment. C. Pertinent dates and times. D. Name of the reporter. E. NO IDENTIFYING INFORMATION ABOUT the alleged perpetrator if known. F. Specific information that might be helpful in investigating the alleged abuse, neglect or exploitation; i.e., marks or bruises, conversations, observations, witnesses, etc. Page 4 of 14
2. The President or designee (Director of Programs & Services) shall review the oral and written reports and notify the Common Entry Point if the action is deemed appropriate. In the event that the President has reason to believe that the designee was involved in the suspected or alleged maltreatment, the review and notification shall be conducted by the President. In the event that the Director of Programs and Services (designee ) has reason to believe that the President was involved in the suspected or alleged maltreatment, the review and notification shall be conducted by the Director of Programs and Services. Such reports shall be promptly investigated and reported to the Common Entry Point. Mandated reporters will be informed in writing of the date that the report was sent to outside authorities within two working days. (Form R-132 Vulnerable Adult/Minor Maltreatment Report Form) All ProAct, Inc. employees will cooperate fully in any investigation of suspected maltreatment of a person served. The investigation will be conducted by the Department of Human Services. Records pertaining to any investigation shall disclose the name of the reporter only with the consent of the reporter or upon a written finding by the court that the report was false and that there is evidence that the report was made in bad faith. WHAT DOCUMENTATION MUST BE MAINTAINED BY THE FACILITY? Facilities are required to maintain the following documentation: 1. Evidence that a mandated reporter received a written notice within two working days and in a manner that protected the confidentiality of the reporter: (R-132 - Vulnerable Adult/Minor Maltreatment Reporting Form) A. whether an internal report was forwarded to the CEP; B. that if the internal reporter is not satisfied with the action taken by the facility on whether to report the incident to the CEP, that the reporter may report externally; and C. the reporter has statutory protection from retaliation by the facility for any good faith external report. 2. Documentation of the facility's internal review of an incident of suspected maltreatment. If an internal report is filed, documentation of the review will be provided to the commissioner upon the commissioner s request. 3. Documentation of incidents that are considered "accidents". 4. Documentation of an error in the provision of therapeutic conduct. 5. The requirements for program abuse prevention plans; individual abuse prevention plans; orientation and training of persons receiving services; and orientation and training of staff that are identified in Minnesota Rules, parts 9555.8000 through 9555.8500 (Rule 10) continue to be in effect for all programs licensed by the Department of Human Page 5 of 14
Services without change. The new VAA no longer requires the facility to submit a written report which includes all of the content requirements identified by Minnesota Rules, part 9555.8400, subpart 2. (Rule 10). The information required in this rule is included in the information to be obtained by the CEP at the time that the initial report of suspected maltreatment is made. RECORD KEEPING Records of data disclosed through investigation will be kept according to the following schedule: 1. All data found to be false may be destroyed two years after the finding was made. 2. All data found to be inconclusive may be destroyed four years after the finding was made. 3. All data found to be substantiated may be destroyed seven years after the finding was made. INTERNAL REVIEW An internal review and investigation, and if needed, corrective action, shall be completed on every report of observed or suspected maltreatment of a person served which is known to the agency. The review and investigation must include: an evaluation of whether related policies and procedures were followed, whether the policies and procedures were adequate, whether there is a need for further staff training, whether the reported event is similar to past events with the vulnerable adults or minors or the services involved, and whether there is a need for corrective action to be taken by the facility to protect the health and safety of vulnerable adults or minors. 1. The President or designee shall conduct an internal review and investigation of the incident, using the CEP form (R-132) in cooperation with the law enforcement and/or Human Services personnel assigned to investigate the alleged maltreatment. In the event that the President has reason to believe that the designee' was involved in the suspected or alleged maltreatment, the investigation shall be conducted by the President. In the event that the Director, Programs & Services (designee') has reason to believe that the President was involved in the suspected or alleged maltreatment, the investigation shall be conducted by the Director, Programs & Services. 2. The President or designee and the outside investigative authorities will have access to all reports and records available regarding the alleged or suspected maltreatment depending on superseding laws regarding data privacy. 3. In assisting to conduct any investigation, the President or designee will comply with the provisions of Personnel Policies where the employee may be the subject of disciplinary action. 4. Any accused employee or person served may be suspended during the investigation at the discretion of the President or designee. The employee or participant will be informed of his/her rights to representation during the investigation and all other legal rights. Page 6 of 14
5. The President or designee will provide in the case of participant to participant abuse a report of the investigation to the Client Services Committee following its conclusion. 6. The President or designee will provide reports as indicated to the Department of Human Services and/or others as necessary. CORRECTIVE ACTION PLAN: When the investigation has been completed, the President will review the investigation to determine the appropriate corrective actions, if any. The accused employee or participant shall be notified promptly of the results of the investigation in a manner deemed appropriate. Any employee/participant who intentionally files a false report may be disciplined and liable for damages in a civil suit. Any employee/participant, who intentionally fails to report abuse may also be disciplined, found guilty of a misdemeanor and liable for damages caused by such failure. 1. If the allegation is false, no report will be filed in the employee's personnel file. Records will be kept, however, for two years. 2. If the report cannot be substantiated or disproved no report shall be filed in the employee's or participant's personnel file; 3. If the allegation is proven, appropriate corrective action will be assessed the employee or participant and a record retained both by the President and in the staff personnel or case file for seven years. 3. If the employee remains employed, a corrective action program will be developed, documented, and implemented. It will be designed to correct current lapses and prevent future lapses in performance by the individual or ProAct to prevent recurrence of this behavior. This may include, but not be limited to, in-service education, individual counseling, additional supervision, reassignment of duties, and the Employee Assistance Program. This program will be documented in the employee/participant file. STAFF TRAINING: ProAct will ensure that each new mandated reporter receives an orientation within 72 hours of first providing direct contact services to a vulnerable adult or minor and annually thereafter. The orientation and annual review shall inform the mandated reporters of the reporting requirements and definitions specified under Minnesota Statutes, sections 626.557 and 626.5572, the requirements of Minnesota Statutes, section 245A.65, the license holder s program abuse prevention plan, and all internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services. ProAct must document the provision of this training, monitor implementation by staff, and ensure that the policy is readily accessible to staff, as specified under Minnesota Statutes, section 245A.04, subdivision 14. Page 7 of 14
PROTECTION: Any person, who in good faith reports suspected maltreatment of a person served who is the subject of such report, is protected from retaliation by the facility or person therein. This immunity must be made known to the reporter by a written action letter within two working days. The source of the report will remain confidential within the agency and through the course of legal action in so far as the law allows. 1. Any retaliatory action received by the reporter of suspected maltreatment shall be reported to the President or designee. 2. Any facility or person who retaliates against any reporter is legally liable for damages and fine. 4. Any person who makes a good faith (an honest belief in its truth) report is immune from civil suit or liability even if the report is false or not substantiated. DEFINITIONS The following definitions are examples of, but are not limited to, this list: 1. Serious Maltreatment A. Serious maltreatment means sexual abuse, maltreatment resulting in death, maltreatment resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. B. For the purposes of this definition, care of a physician is treatment received or ordered by a physician but does not include diagnostic testing, assessment, or observation. C. For purposes of this definition, abuse resulting in serious injury means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. D. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. Page 8 of 14
2. "ABUSE" means: A. An act against a vulnerable adult or minor that constitutes a violation of, an attempt to violate, or aiding and abetting a violation of: a. assault in the first through fifth degrees as defined in sections 609.221 to 609.224; b. the use of drugs to injure or facilitate crime as defined in section 609.235; c. the solicitation, inducement, and promotion of prostitution as defined in section 609.322; and d. criminal sexual conduct in the first through fifth degrees as defined in sections 609.342 to 609.3451. A violation includes any action that meets the elements of the crime, regardless of whether there is a criminal proceeding or conviction. B. Conduct which is not an accident or therapeutic conduct as defined in this section, which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to, the following; a. hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult or minor; b. use of repeated or malicious oral, written, or gestured language toward a vulnerable adult or minor or the treatment of a vulnerable adult or minor which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening; c. use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult or minor from other persons against the will of the vulnerable adult or minor or the legal representative of the vulnerable adult or minor; and d. use of any aversive or deprivation procedures for persons with developmental disabilities or related conditions not authorized under section 245.825. C. Any sexual contact or penetration as defined in section 609.341, between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. D. The act of forcing, compelling, coercing, or enticing a vulnerable adult against the vulnerable adult's or minor s will to perform services for the advantage of another. E. For purposes of this section, a vulnerable adult or minor is not abused for the sole reason that the vulnerable adult or minor or a person with authority to make health care decisions for the vulnerable adult or minor under sections 144.651, 144A.44, chapter 145b, 145c or 252a, or section 253B.03 or 525.539 to 525.6199, refuses consent or withdraws consent, consistent with that authority and within the boundary of reasonable medical practice, to any therapeutic conduct, including any care, service, or procedure to diagnose, maintain, or treat the physical or mental Page 9 of 14
condition of the vulnerable adult or minor or, where permitted under law, to provide nutrition and hydration parenterally or through intubations. This paragraph does not enlarge or diminish rights otherwise held under law by: a. a vulnerable adult or minor or a person acting on behalf of a vulnerable adult or minor, including an involved family member, to consent to or refuse consent for therapeutic conduct; or b. a caregiver to offer or provide or refuse to offer or provide therapeutic conduct. F. For purposes of this section, a vulnerable adult or minor is not abused for the sole reason that the vulnerable adult or minor, a person with authority to make health care decisions for the vulnerable adult or minor, or a caregiver in good faith selects and depends upon spiritual means or prayer for treatment or care of disease or remedial care of the vulnerable adult or minor in lieu of medical care, provided that this is consistent with the prior practice or belief of the vulnerable adult or minor or with the expressed intentions of the vulnerable adult or minor. G. For purposes of this section, a vulnerable adult or minor is not abused for the sole reason that the vulnerable adult or minor, who is not impaired in judgement or capacity by mental or emotional dysfunction or undue influence, engages in consensual sexual contact with: a. a person, including a facility staff person, when a consensual sexual personal relationship existed prior to the care giving relationship; or b. a personal care attendant, regardless of whether the consensual sexual personal relationship existed prior to the care giving relationship. 3. "Accident" means: A sudden, unforeseen, and unexpected occurrence or event which: A. is not likely to occur and which could not have been prevented by exercise of due care; and B. if occurring while a vulnerable adult or minor is receiving services from a facility, happens when the facility and the employee or person providing services in the facility are in compliance with the laws and rules relevant to the occurrence or event. Page 10 of 14
4. "Financial exploitation" means: A. In breach of a fiduciary obligation recognized elsewhere in law, including pertinent regulations, contractual obligations, documented consent by a competent person, or the obligations of a responsible party under section 144.6501 a person: a. engages in unauthorized expenditure of funds entrusted to the actor by the vulnerable adult or minor which results or is likely to result in detriment to the vulnerable adult or minor; or b. fails to use the financial resources of the vulnerable adult or minor to provide food, clothing, shelter, health care, therapeutic conduct or supervision for the vulnerable adult or minor, and the failure results or is likely to result in detriment to the vulnerable adult or minor. B. In the absence of legal authority a person: a. willfully uses, withholds, or disposes of funds or property of a vulnerable adult or minor; b. obtains for the actor or another the performance of services by a third person for the wrongful profit or advantage of the actor or another to the detriment of the vulnerable adult or minor; c. acquires possession or control of, or an interest in, funds or property of a vulnerable adult or minor through the use of undue influence, harassment, duress, deception, or fraud; or d. forces, compels, coerces, or entices a vulnerable adult or minor against the vulnerable adult's or minor s will to perform services for the profit or advantage of another. C. Nothing in this definition requires a facility or caregiver to provide financial management or supervise financial management for a vulnerable adult or minor except as otherwise required by law. 5. "Immediately" means: As soon as possible, but no longer than 24 hours from the time initial knowledge that the incident occurred has been received. Page 11 of 14
6. Incident means: A. Serious injury as determined by section 245.91, subdivision 6. B. A consumer s death. C. Any medical emergencies, unexpected serious illnesses, or accidents that require physician treatment or hospitalization. D. A consumer s unauthorized absence. E. Any fires or other circumstances involving a law enforcement agency. F. Physical aggression by a consumer against another consumer that causes physical pain, injury, or persistent emotional distress, including, but not limited to, hitting, slapping, kicking, scratching, pinching, biting, pushing, and spitting. G. Any sexual activity between consumers involving force or coercion as defined under section 609.341, subdivision3. H. A report of a child or vulnerable adult maltreatment under section 626.556 or 626.557. Providers must also maintain information about verbal aggression between consumers and self-abuse affecting the consumer. 7. Neglect" means: A. The failure or omission by a caregiver to supply a vulnerable adult or minor with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: a. reasonable and necessary to obtain or maintain the vulnerable adult's or minor s physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult or minor; and b. which is not the result of an accident or therapeutic conduct. B. The absence or likelihood of absence of care or services, including but not limited to, food, clothing, shelter, health care, or supervision necessary to maintain the physical and mental health of the vulnerable adult or minor which a reasonable person would deem essential to obtain or maintain the vulnerable adult's or minor s health, safety, or comfort considering the physical or mental capacity or dysfunction of the vulnerable adult or minor. C. For purposes of this section, a vulnerable adult or minor is not neglected for the sole reason that: a. the vulnerable adult or minor or a person with authority to make health care decisions for the vulnerable adult or minor under sections 144.651, 144A.44, Page 12 of 14
chapter 145B, 145C, or 252A, or section 253B.03, or 525.539 to 525.6199, refuses consent or withdraws consent, consistent with that authority and within the boundary of reasonable medical practice, to any therapeutic conduct, including any care, service, or procedure to diagnose, maintain, or treat the physical or mental condition of the vulnerable adult or minor, or, where permitted under law, to provide nutrition and hydration parenterally or through intubation; this paragraph does not enlarge or diminish rights otherwise held under law by: (i) a vulnerable adult or minor or a person acting on behalf of a vulnerable adult or minor, including an involved family member, to consent to or refuse consent for therapeutic conduct; or (ii) a caregiver to offer or provide or refuse to offer or provide therapeutic conduct; or b. the vulnerable adult or minor, a person with authority to make health care decisions for the vulnerable adult or minor or a caregiver in good faith selects and depends upon spiritual means or prayer for treatment or care of disease or remedial care of the vulnerable adult or minor in lieu of medical care, provided that this is consistent with the prior practice or belief of the vulnerable adult or minor or with the expressed intentions of the vulnerable adult or minor; c. the vulnerable adult or minor, who is not impaired in judgement or capacity by mental or emotional dysfunction or undue influence, engages in consensual sexual contact with: (i) a person including a facility staff person when a consensual sexual personal relationship existed prior to the caregiving relationship; or (ii) a personal care attendant, regardless of whether the consensual sexual personal relationship existed prior to the caregiving relationship; or d. an individual makes an error in the provision of therapeutic conduct to a vulnerable adult or minor which: (i) does not result in injury or harm which reasonably requires medical or mental health care; (ii) an individual makes an error in the provision of therapeutic conduct to a vulnerable adult or minor that results in injury or harm, which reasonably requires the care of a physician, and (iii) the necessary care is provided in a timely fashion as dictated by the condition of the vulnerable adult or minor, (iv) if after receiving care, the health status of the vulnerable adult or minor can be reasonably expected, as determined by the attending physician, to be restored to the vulnerable adult s or minor s preexisting condition, (v) the error is not part of a pattern of errors by the individual, (vi) is immediately reported internally by the employee or person providing services in the facility; (vii) if in a facility, the facility identifies and takes corrective action and implements measures designed to reduce the risk of further occurrence of this and similar errors; and (viii) is sufficiently documented for review and evaluation by the facility and any applicable licensing and certification agency. D. Nothing in this definition requires a caregiver, if regulated, to provide services in excess of those required by the caregiver's license, certification agency. Page 13 of 14
8. "Therapeutic conduct" means: The provision of program services, health care, or other personal care services done in good faith in the interest of the vulnerable adult or minor by: A. an individual, facility, or employee or person providing services in a facility under the rights, privileges and responsibilities conferred by state license, certification, or registration; or B. a caregiver. THIS REPORTING POLICY MUST BE POSTED IN A PROMINENT PLACE, AND BE MADE AVAILABLE UPON REQUEST. Page 14 of 14