MANDATED REPORTING OF MALTREATMENT AND INTERNAL REVIEW POLICY FOR VULNERABLE ADULTS AND MINORS

Policy:

  1. PossAbilities will protect the adults served by our programs who are vulnerable to maltreatment and report known or suspected maltreatment of vulnerable adults.
  2. PossAbilities will protect children served by our programs whose health or welfare may be jeopardized through physical abuse, neglect or sexual abuse.
  3. PossAbilities will not retaliate against any mandated reporter for reports made in good faith.
  4. The agency will not retaliate against a vulnerable adult or a minor with respect to whom a report is made.
  5. PossAbilities will comply fully with Minnesota Statutes and cooperate with the Minnesota Department of Human Services or other authorities in the course of any investigation regarding vulnerable adults or children.

Policy Distribution

  1. A copy of this policy will be posted at each facility owned or leased by PossAbilities of Southern Minnesota.
  2. A copy of this policy will be included in all agency Policy & Procedure manuals and Board of Director notebooks.
  3. A copy of this policy will be provided to all agency mandated reporters, service participants and legal representatives.

Policy Training & Orientation Procedures for Participants

  1. Upon service initiation the Program Director or Coordinatorwill provide the participant and/or their authorized or legal representative with a copy of this policy and orientation to the internal and external reporting procedures within 24 hours of admission to services, or for participants who would benefit from a later orientation, the orientation may take place within 72 hours of admission.
  2. The Program Director or Coordinator will assure the participant and/or their authorized or legal representative signs the Participant Orientation/Training Verification indicating receipt of orientation to this policy and procedures.
  3. The Program Director or Coordinator will assure all documentation regarding this orientation is placed in the participant’s individual program file.

Policy Training & Orientation Procedures for Staff

  1. The Program Director or Coordinator will provide each new staff with a copy of this policy and orientation to the policy and procedures within 72 hours of first providing direct contact services to a vulnerable adult or minor.
  2. The Program Director or Coordinator will provide each new staff with a copy of the Program Abuse Prevention Plan (for facilities owned or leased by PossAbilities only) and orientation to the plan within 72 hours of first providing direct contact services to a vulnerable adult or minor.
  3. The Program Director or Coordinator will provide each new staff with training on Individual Abuse Prevention Plans for all participants the staff will be working with before they provide unsupervised direct contact with the participant.
  4. The Program Director, Coordinatoror Designated Trainer will provide each staff with training on this policy and procedure annually.

Revised 7/17/17 Mandated Reporting/Maltreatment Policy Page 1 of 11

Reviewed and approved by Leadership Team

  1. The Program Director or Coordinator will assure documentation regarding the orientation and annual training is placed in the individual staff file.

Program Abuse Prevention Plan Development and Review

  1. The Program Director(s)or Coordinator(s) in conjunction with the Health & Safety Work Group, will conduct an annual assessment of the population, environment and physical plant for facilities owned or leased by PossAbilities and develop a Program Abuse Prevention Plan for each facility.
  • Population assessment will include an evaluation of the following factors: age, gender, mental functioning, physical and emotional health or behavior of the individuals receiving services; the need for specialized programs of care for individuals, the need for staff training to meet identified individual needs and any knowledge of previous maltreatment that is relevant to minimizing risk of maltreatment of individuals receiving service.
  • Physical plant assessment will include an evaluation of the following factors: the condition and design of the building as it relates to safety of individuals receiving services and the existence of areas in the building that are difficult to supervise.
  • Environmental assessment will include an evaluation of the following factors: the location of the program in a particular neighborhood or community, the traffic patterns in the area, the type of grounds and terrain surrounding the building; the type of internal programming and the program’s staffing patterns.
  • The annual assessment will include corrective action(s) and a timetable for the identified corrective action needed to minimize risk(s) for the individuals receiving service.
  1. The Program Director or Coordinator will assure that a copy of the Program Abuse Prevention Plan is posted in a prominent place in the facility.
  2. A copy of this policy will be provided to all agency mandated reporters, service participants and legal representatives.
  3. The Program Director or Coordinator will assure PossAbilities’ Board of Directors reviews each facilities Program Abuse Prevention plan at least annually.

Vulnerable Adults

Individual Abuse Prevention Plan Development and Review

  1. The Program Director, Coordinator, Specialist or Consultant assigned to the participant, in conjunction with the participant and their authorized or legal representative, if applicable, will develop an Individual Abuse Prevention Plan for each vulnerable adult receiving services from PossAbilities as part of the initial individual program plan.
  2. The Individual Abuse Prevention Plan will contain:
  3. An assessment of the participant’s susceptibility to maltreatment when it indicates the need for measures in addition to the specific measures identified in the Program Abuse Prevention Plan (discussed above); and
  4. The plan must include a statement of measures to be taken to minimize the risk of maltreatment of the participant. This includes identifying referrals that are made when the participant is susceptible to abuse outside the scope or control of the licensed services.
  5. A statement of the specific measures to be taken to minimize the risk of maltreatment to that participant within the scope of the services being provided by PossAbilities of Southern Minnesota.
  6. If the assessment indicates that the vulnerable adult does not need specific risk reduction measures in addition to those identified in the program abuse prevention plan, the individual abuse prevention plan must document this determination.
  7. The Program Director, Coordinator, Specialist or Consultant assigned to the participant will assure the initial Individual Abuse Prevention Plan is reviewed and revised as needed as part of the participant’s 45 day review.
  8. The Program Director, Coordinator, Specialist or Consultant assigned to the participant, along with the participant and their support team, will review and update the Individual Abuse Prevention Plan at least annually based on the participant’s needs, changes and any reports of maltreatment in relation to the participant.
  9. The Program Director, Coordinator, Specialist or Consultant assigned to the participant will assure the participant and/or their authorized or legal representative approve, sign and date the Individual Abuse Prevention Plan.
  10. The Program Director, Coordinator, Specialist or Consultant assigned to the participant will assure a copy of the signed Individual Abuse Prevention Plan is placed in the participant’s individual program file.

Procedures for Reporting Maltreatment of Vulnerable Adult

  1. All PossAbilities staff are considered mandated reporters and must make a report if you know or suspect that a vulnerable adult has been maltreated.The report must be made immediately but no longer than 24 hours from when you had knowledge that the incident occurred.
  2. PossAbilities staff must report maltreatment of vulnerable adults as defined in Minnesota Statutes Section 656.5572 (see Appendix A)
  3. PossAbilities staff who negligently or intentionally fail to report suspected maltreatment of a vulnerable adult are liable for damages caused by the failure to report and may be subject to disciplinary action or termination from employment.
  4. Reports can be made either externally or internally to:
  5. External Report – Contact the Minnesota Adult Abuse Reporting Center at 844-880-1574.
  6. Internal Report – Make an initial verbal report to a Program Director, Coordinator or the Executive Director. You must report to someone who is not involved in the alleged or suspected maltreatment. Complete the PossAbilities Maltreatment Incident Internal Report within 24 hours of the verbal report and submit to a Program Director, Coordinator or the Executive Director.
  7. An external or internal report should contain, at a minimum, the following information:
  8. Information to identify the vulnerable adult;
  9. Information to identify the staff or caregiver(s) involved in the incident;
  10. The nature and extent of the suspected maltreatment;
  11. Any evidence of previous maltreatment;
  12. The name and address of the reporter;
  13. The time, date and location of the incident; and
  14. Any other information that the reporter believes might be helpful in investigating the suspected maltreatment.

Procedures for Receipt of Internal Report

  1. When an internal report is received, the Program Director, Coordinator or Executive Director, is responsible for deciding if a report to the Minnesota Adult Abuse Reporting Center is required.
  2. The Program Director, Coordinatoror Executive Director will make the report to the Minnesota Adult Abuse Reporting Center as soon as possible, but no longer than 24 hours from the time of initial knowledge of the internal report.
  3. Within two working days, the Program Director, Coordinatoror Executive Director receiving the report must provide the mandated reporter with a copy of the Confidential Mandated Reporter Notification.

Procedure for Internal Review of Maltreatment Report

  1. When PossAbilities has reason to know that an internal or external report of alleged or suspected maltreatment has been made, the program must complete an internal review within 30 calendar daysand take corrective action, if necessary, to protect the health and safety of vulnerable adults receiving services.
  2. The internal review will be completed by a Program Director, Coordinator or Executive Director. The internal review may not be completed by someone involved in the alleged or suspected maltreatment.
  3. The Program Director, Coordinatoror Executive Director will complete the written Internal Review of Maltreatment form that includes an evaluation of whether:
  4. Related policies and procedures were followed;
  5. The policies and procedures were adequate;
  6. There is a need for additional staff training;
  7. The reported event is similar to past events with the participants or the services involved; and
  8. There is a need for corrective action by PossAbilities to protect the health and safety of vulnerable adults receiving services.
  9. Based on the results of the internal review PossAbilities will develop, document and implement a corrective action plan as necessary to correct current lapses and prevent future lapses in performance by staff or PossAbilities as an agency.
  10. The Program Director, Coordinatoror Executive Director will assure a copy of the Internal Review of Maltreatment form is placed in the agency’s Maltreatment Investigations file.
  11. A copy of the Internal Review of Maltreatment form will be provided to the Minnesota Department of Human Services upon request.

Minors

Procedures for Reporting Maltreatment of a Minor

  1. All PossAbilities staff are considered mandated reporters and must make a report to an outside agency if you know or suspect that a minor has been neglected or physically or sexually abused within the preceding three years. The report must be made immediately but no longer than 24 hours from when you had knowledge that the incident occurred.
  2. PossAbilities staff must report maltreatment of minors as defined in Minnesota Statutes Section 656.556 (see Appendix B)
  3. PossAbilities staff who negligently or intentionally fail to report suspected maltreatment of a minor is guilty of a misdemeanor and may be subject to disciplinary action or termination from employment. In addition, a mandated reporter that fails to report maltreatment that is found to be serious or recurring may be disqualified from employment in positions in programs licensed by the Department of Human Services, Department of Health and unlicensed Personal Care Provider Organizations.
  4. If you know or suspect that a child is in immediate danger you must call 911.
  5. All reports of suspected abuse or neglect of children occurring at PossAbilities must be made to the Department of Human Services, Licensing Division’s Maltreatment Intake line at 651-431-6600.
  6. All reports of suspected abuse or neglect of children occurring within a family or the community should be made to the local county social services agency at:
  7. Dodge County 507-635-6170 (day) 507-635-6200 (eve/wknd)
  8. Fillmore County 507-765-2175 (day) 507-765-3874 (eve/wknd)
  9. Goodhue County 651-385-3232 (day) 651-385-3155 (eve/wknd)
  10. Houston County 507-725-5811 or 507-725-5838 Ext.1288 (day) 507-725-3379 (eve/wknd)
  11. Mower County 507-437-9700 (day) 507-437-9400 (eve/wknd)
  12. Olmsted County 507-328-6400 (day) 507-281-6248 (eve/wknd)
  13. Rice County 507-332-6115 (day) 1-800-422-1286 (eve/wknd)
  14. Steele County 507-444-7500 (day) 507-451-8232 (eve/wknd)
  15. Wabasha County 651-565-3351 (day) 651-565-3361 (eve/wknd)
  16. Winona County 507-457-6500 (day) 507-457-6368 (eve/wknd)

or local law enforcement by calling 911 or:

  • Dodge County 507-635-6200
  • Fillmore County 507-765-3874
  • Goodhue County 651-385-3155
  • Houston County 507-725-3379
  • Mower County 507-437-9400
  • Olmsted County 507-285-8580
  • Rice County 507-332-6100
  • Steele County 507-451-8232
  • Wabasha County 651-565-3361
  • Winona County 507-457-6368
  1. Reports that involve possible violations of Minnesota Statutes or Rules that govern the facility should be reported to the Department of Human Services, Licensing Division at 651-431-6500.
  2. An oral report of suspected abuse or neglect made to one of the above agencies must be followed by a written report to the same agency within 72 hours, exclusive of weekends and holidays.
  3. An external report should contain, at a minimum, the following information:
  4. Information to identify the child involved;
  5. Any persons responsible for the abuse or neglect, if known;
  6. The nature and extent of the suspected maltreatment and/or possible licensing violations;
  7. Any evidence of previous maltreatment;
  8. The name and address of the reporter;
  9. The time, date and location of the incident; and
  10. Any other information that the reporter believes might be helpful in investigating the suspected maltreatment.

Procedure for Internal Review of Maltreatment Report

  1. When PossAbilities has reason to know that an external report of alleged or suspected maltreatment has been made, the program must complete an internal review within 30 daysand take corrective action, if necessary, to protect the health and safety of minors receiving services.
  2. The internal review will be completed by a Program Director, Coordinator or the Executive Director. The internal review may not be completed by someone involved in the alleged or suspected maltreatment.
  3. The Program Director, Coordinatoror Executive Director will complete the written Internal Review of Maltreatment form that includes an evaluation of whether:
  4. Related policies and procedures were followed;
  5. The policies and procedures were adequate;
  6. There is a need for additional staff training;
  7. The reported event is similar to past events with the participants or the services involved; and
  8. There is a need for corrective action by PossAbilities to protect the health and safety of minors receiving services.
  9. Based on the results of the internal review PossAbilities will develop, document and implement a corrective action plan as necessary to correct current lapses and prevent future lapses in performance by staff or PossAbilities as an agency.
  10. The Program Director, Coordinatoror Executive Director will assure a copy of the Internal Review of Maltreatment form is placed in the agency’s Maltreatment Investigations file.
  11. A copy of the Internal Review of Maltreatment form will be provided to the Minnesota Department of Human Services upon request.

APPENDIX A

MN STATUTE 626.5572

VULNERABLE ADULTS DEFINITIONS

Subd. 21.Vulnerable adult.

(a) "Vulnerable adult" means any person 18 years of age or older who:

(1) is a resident or inpatient of a facility;

(2) receives services at or from a facility required to be licensed to serve adults under sections 245A.01 to 245A.15, except that a person receiving outpatient services for treatment of chemical dependency or mental illness, or one who is served in the Minnesota sex offender program on a court-hold order for commitment, or is committed as a sexual psychopathic personality or as a sexually dangerous person under chapter 253B, is not considered a vulnerable adult unless the person meets the requirements of clause (4);

(3) receives services from a home care provider required to be licensed under section 144A.46; or from a person or organization that exclusively offers, provides, or arranges for personal care assistance services under the medical assistance program as authorized under sections 256B.04, subdivision 16, 256B.0625, subdivision 19a, 256B.0651, 256B.0653 to 256B.0656, and 256B.0659; or

(4) regardless of residence or whether any type of service is received, possesses a physical or mental infirmity or other physical, mental, or emotional dysfunction:

(i) that impairs the individual's ability to provide adequately for the individual's own care without assistance, including the provision of food, shelter, clothing, health care, or supervision; and

(ii) because of the dysfunction or infirmity and the need for care or services, the individual has an impaired ability to protect the individual's self from maltreatment.

(b) For purposes of this subdivision, "care or services" means care or services for the health, safety, welfare, or maintenance of an individual.

Subd. 15.Maltreatment.

"Maltreatment" means abuse as defined in subdivision 2, neglect as defined in subdivision 17, or financial exploitation as defined in subdivision 9.

Subd.2.Abuse.

"Abuse" means:

(a) An act against a vulnerable adult that constitutes a violation of, an attempt to violate, or aiding and abetting a violation of:

(1) assault in the first through fifth degrees as defined in sections 609.221 to 609.224;

(2) the use of drugs to injure or facilitate crime as defined in section 609.235;

(3) the solicitation, inducement, and promotion of prostitution as defined in section 609.322; and

(4) 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:

(1) hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult;