Regulatory Review Recommendations by the Betsy Lehman Center to the Department of Public

Regulatory Review Recommendations by the Betsy Lehman Center to the Department of Public Health:

Patient and Resident Abuse—Reporting obligations and procedures [105 CMR § 155.000]

/ Regulation(s) / Observation / Recommendation / Notes /
PATIENT AND RESIDENT ABUSE—REPORTING OBLIGATIONS AND PROCEDURES
Scope of obligations
1 / 105 CMR §155.004(A, B) / Mandatory reporter vs. facility obligation
1)  A facility’s reporting obligations are unclear in cases where a mandatory reporter reports directly to the Department.
2)  Is it unclear whether or not a facility’s reporting obligations under §155. 010(A)(1) (Patient Abuse—Responsibilities of the Facility) and §105.002(G)(2) (LTC Licensing- Serious Incidents) are satisfied when a mandatory reporter’s supervisor reports to DPH under §155.004(A) or (B), and whether this depends on the supervisor’s method of reporting (i.e. phone vs. fax/electronic communication). / Clarify the facility’s reporting obligations when a mandatory reporter or supervisor makes an initial report to the Department, whether by regulations and/or guidance. / Because this observation pertains to both 105 CMR § 155.000 and 105 CMR § 150.002 (“Standards for Long-Term Care Facilities), we repeat this recommendation in the Center’s public comment on 105 CMR § 150.000.
2 / 105 CMR § §155.002 / Facility types covered
105 CMR 155.000 applies to a more narrow set of long-term care facilities than those covered by 105 CMR 150.000 (“Standards for Long-Term Care Facilities”).
105 CMR §155 only applies to facilities licensed under M.G.L. c.111, §71; however, long-term care facilities, as defined in 105 CMR § 150, refers to a more expansive list of facilities, creating a gap in reporting obligations. / Clarify by regulation and/or guidance which long-term care facilities are covered by 105 CMR §155 and how that affects reporting obligations for abuse and neglect.
Reporting procedures
3 / 105 CMR § 150.002 (G)(2) / Mechanism for immediately reporting abuse and neglect (phone vs. email/fax)
It is unclear how long-term care facilities should immediately report instances of abuse and neglect given a discrepancy between Department guidance and 105 CMR §§ 155.004.
According to Circular Letter: DHCQ 13-9-599, LTC facilities should report all immediately reportable incidents—which include suspected instances of resident abuse and neglect—by phone.
However, 105 CMR §§ 155.004 (A,B) allows reporters to make initial reports of abuse by “electronically transmitted report or facsimile.” Also, the Department’s online instructions for reporting abuse and neglect (“Facility reporting to DPH” webpage) suggest that the only incidents required to be immediately reportable by phone are unanticipated deaths and evacuations—not all cases of suspected abuse/neglect. / Reconcile any conflicting regulations and guidance that specify how long-term care facilities should immediately report suspected instances of abuse or neglect. / Because this observation pertains to discrepancies between 105 CMR § 155.000 and 105 CMR § 150.002 (Standards for Long-Term Care Facilities), we include the same recommendation in the Center’s public comment on 105 CMR § 150.000.

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