Louisiana Department of Health

Health Standards Section

Self-ReportingProcess for Hospitals – Abuse/Neglect

(Revised 12/19/2017)

  1. Abuse/Neglect Handout

The goal in providing this handout is to facilitate the self-reporting of allegations and/or suspicion of abuse/neglect occurring within the facility, in accordance with Louisiana law. Pursuant toLA R.S. 40:2009.20 facilities/health care workers shall report these allegations within 24 hours of receiving knowledge of the allegationto either the local law enforcement agency or the Department of Health and Hospitals (LDH) (or the Medicaid Fraud Unit as applicable). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division,and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence. It is important to remember that use of the words “abuse,” “neglect,” or “grievance,” are not required to categorize a scenario as a potential abuse/neglect grievance. Additionally, allegations received after the patient’s discharge, whether received from the patient, a family member, or another agency or healthcare provider, must be treated in the same manner as indicated above. Please note: In accordance with CMS §482.13, an allegation of abuse or neglect must be reported and processed as a grievance, regardless of whether the complainant recants the allegation or expresses satisfaction with resolution. Staff members’ assurance that the allegation is unsubstantiated is not relevant to this process (other than to provide supporting evidence as part of the investigation).

  1. Health Standards Section (HSS) Objective

The objective of the Health Standards Section (HSS) of Louisiana Department of Health (LDH) in receiving self-reports of abuse/neglect is to determine whether a licensed facility has systems in place to prevent occurrences of internal abuse and neglect. Information provided by a hospital to HSS should reflect an understanding on the part of front-line staff and administration, that concerns and allegations about abuse/neglect should be elevated through the chain of command immediately, so that an investigation may be initiated and appropriate internal and externalreporting is completed. Additionally, this office must be able to verify that the facility responded appropriately to a witnessed, reported, or alleged event in terms of patient safety, compliance with statutes and regulations, and prevention of future occurrences. In addition to conducting a thorough investigation, the facility is required to demonstrate specific actions taken prior and subsequent to such events with regard to prevention (i.e. pre-hire screening, education, and training), reporting, and personnel actions taken (both disciplinary and educational) prior to, during, or as a result of the investigation.

  1. Who Should Receive This Information

This information should be shared with all hospital personnel, particularly those that are involved with investigating and/or reporting allegations/suspicions of abuse or neglect occurring within the facility and/or the grievance process. All administrative and supervisory personnel should be aware of this information. All personnel should be madeaware of the importance of notifying supervisors of potential abuse/neglect situations so the information may be escalated accordingly.Supervisory personnel should be directed to inform administrative personnel (present or on call) immediately so that the required processes may commence.

  1. Self-Reporting

In the interest of providing information that will indicate the facility’s compliance with CMS Regulation 482.13(c) (3) regarding abuse, neglect, and harassment, as well as La R.S. 40:2009.20, the following processes have been developed. It should be noted that a facility’s decision to self-report does not eliminate the possibility of an onsite investigation being conducted in response to allegations and/or relevant information received.

Although LA R.S. 40:2009.20 requires a facility to report knowledge of incidents of abuse, within twenty-four hours, to either the local law enforcement agency or Louisiana Department of Health (or the Medicaid Fraud Unit as applicable), many facilities find it beneficial to self-report to LDH even if they have notified law enforcement. It is important to note that contacting law enforcement on behalf or at the request of the patient/complainant (e.g. to press charges, etc.) does not satisfy the statute’s intent regarding facility notification.

Please do not leave self-report notifications on the Hospital Hotline!!!

Janice Louis, RN, is currently the Hospitals Program Manager that receives and processes self-reports. The initial and final reportsshall be emailed to via an encrypted/secure email. As indicated above, the initial report must be submitted within 24 hours of awarenessof the incident/allegation/suspicion. Since hospitals must operate 24 hours a day, seven days a week, no adjustment is made to accommodate weekends or holidays. In other words, if an event is noted to occur (or an allegation is received) on Friday at 10:30 p.m., the initial report shall be emailed no later than Saturday at 10:30 p.m.

E-mails are automatically tagged with the date and time of receipt, providing proof that reports were submitted in a timely manner. The phone number and e-mail address listed below are relevant to hospitals only.

  1. Contact Information for Self-Reporting

Janice Louis, BSN, RN-BC, CLNC

Medical Certification Program Manager

E-mail:

Direct Phone: 225-342-5775

  1. Format for Submitting Self-Reports

A Hospital Abuse Neglect Initial Report form has been developed by HSS (HSS-HO-41). It is one of the attachments sent out with these guidelines. The form, along with instructions for completion of the form, is also available on the LDHwebsite at (under the link “Hospital Abuse/Neglect Reporting Form” near the bottom of the page). The form was designed for ease of completion on a computer; the white spaces are designed to expand to accommodate as much information as the author wishes to include. If the form is completed on a computer, it is recommended that the completed document be saved and emailed to HSS per an encrypted/secure email.

Format for Submitting Self-Reports (cont’d)

Although use of this form is not required, you are encouraged to utilize it. In the event that you choose not to make use of the form, please ensure that the initial report you submit provides at least the information requested on the form. Your initial report (if you choose not to use the HSS form),may be submitted on your facility’s forms and/or letterhead; please ensure that all documents are clearly identified with the name of your facility and the date of the occurrence.

Many facilities include copies of documents from patient records, if pertinent to the investigation (e.g. if a patient makes an allegation that is considered “outrageously improbable,” it is often helpful to include a psychiatric evaluation and/or progress notes describing the patient’s mental status, the administration of narcotics or anesthesia, and/or psychiatric history). You are encouraged to include any documents that you feel are relevant to the initial report, however these documents should be kept to a minimum to conserve resources. All documents submitted shall be via an encrypted/secure email.

In the event that a facility initially includes sufficient information for HSS to conclude that no further documentation is required, the individual submitting the initial report will be notified of this via email. The administrator listed on the initial report will be copied on the email. Such notification does not mean that the hospital should cease its investigation or actions, as the facility has deemed appropriate; it means only that further involvement by HSS is not indicated.

NOTE: If the event involves patients identified as having behavioral health issues and/or cognitive impairment (regardless of the setting), please include the following information in the initial report:

  1. Whether the individual is on an involuntary hold (i.e., PEC, CEC, or JC) or being evaluated for one.
  2. The patient’s observation status prior to, during, and subsequent to, the event.
  3. If the event occurred on a behavioral health unit; the patient census of the unit, the number and types of special observation status patients, the number and types of staff members assigned to and present onthe unit at the time of the event.
  1. Health Standards Section’s Responsibility

The Health Standards Section is required to report allegations of abuseand neglect to the Office of the Attorney General and to the Sheriff’s Office for the parish in which the facility is located (or the New Orleans Police Department if the facility is located within that jurisdiction). Notification must occur by close of business on the day after receiving the initial report. This notification is accomplished by HSS sending reports containing the information submitted in the initial report, to the appropriate law enforcement agencies, via facsimile and/or email.

  1. Initial Report (within 24 hours of knowledge)

NOTE: Patient-to-patient assaults (physical or sexual)arenever categorized as “Abuse.” From a LDH standpoint, the issue under review is to determine whether the facility failed to take prudent action to prevent, or respond to, the (alleged) occurrence. These incidents should be examined as alleged “Neglect” (i.e. the hospital’s failure to act with due diligence).

The requirement (per statute) is that potential abuse or neglect be reported within 24 hours of knowledge (awareness) of the allegation, suspicion, or occurrence. At that time we ask that you provide, at a minimum, the information required in the Health Standards’ Hospital Abuse/Neglect Initial Report (HSS-HO-41 attached).

This information is sufficient for the initial report.Email this report, as indicated above. During the investigation we may request additional information.The hospital is expected to forward the Final Investigative Report to HSS upon completion (refer to #11, below). Final reports are due on the 5th working day after the initial report is submitted. Requests for extensions of the due date should be submitted via email and must include the reason for the request.

  1. Video Surveillance

Any facility that maintains video surveillance should include information relative to this system in the facility’s Policies and Procedures related to investigating incidents. If the

surveillance system is capable of recording events; the facility must determine and identify how long surveillance video records are maintained. HSS should be made aware of whether video records exist relevant to an alleged occurrence. Such records should be reviewed byAdministration(or designee) as soon as practicable. Information obtained from reviewing video records should be included in the Initial Report if available. Please describe the content of any available video surveillance in detail (i.e., include times and specific observations).

  1. Policy Review Recommendations

A review of policies and procedures should be conducted on a regular basis (at least annually per licensing regulation) and subsequent to relevant incidents/events. The policies and procedures to be reviewed include (but are not limited to):

  1. Abuse/Neglect Policies and Procedures (including reporting and investigation thereof)
  2. Grievance/Complaint Policies and Procedures
  3. Staffing Policies and Procedures (to include staffing guidelines and acuity-based adjustments)
  4. Levels of Observation and/or Nursing Rounds Policies and Procedures
  5. Use of Video Surveillance Policies and Procedures

This review should be performed with regard to ensuring that policies and procedures are compliant with local, state, and federal statutes and regulations, that they can realistically be followed, that the procedural directions are specific enough to provide clear guidance to personnel, and that policies reflect actual practice. If a discrepancy exists, it should be reconciled in a viable manner.

  1. Facility Investigation (Administrative Review)and Final Investigative Report

The Final Investigative Report should be submitted to HSS as soon as it is concluded, but within five working days of submitting the initial report. The hospital may submit additional information (such as completion of staff education, etc.) after the Final Investigative Report has been submitted. An addendum of this nature should clearly identify the hospital, the date of the incident, and must include enough information to link the document to the appropriate incident/event. Final reports and attached documents should be submitted via email, whenever possible, and should be encrypted as they will contain Protected Health Information (PHI).

The final report should provide evidence that the facility conducted a thorough investigation and took measures to prevent future incidents. Issues with hospital systems, policies and procedures, regular practices that contributed to the event should be scrutinized and identified in the report.Specific actions taken in regard to systems and personnel involved should be documented (e.g., education, disciplinary actions, policy revisions, etc.). The final reportmust indicate whether the allegations were substantiated or not (it is acceptable to state that allegations were unable to be substantiated due to lack of evidence).

It is recommended that a facility maintain thorough documentation of witnessed and/or alleged incidents of abuse/neglect for the dual purpose of self-reporting and providing satisfactory evidence of regulatory compliance. During many types of surveys, surveyors may request to see an example of an abuse allegation report and its subsequent investigation.

In accordance with regulations, facilities are directed to process an allegation of abuse or neglect as a grievance in accordance with facility Grievance Processes and Abuse/Neglect policies. In accordance with §482.13, an allegation of abuse/neglect is to be treated as a grievance even if the complainant recants or indicates that the issue is resolved. Awritten response must be issued to the reporting patient or patient’s representative. In many cases, the presentation of an abuse investigation handled in this manner will satisfy surveyor reviews related to the manner in which a facility processes grievances.

At the time that the Final Investigative Report is submitted, information available to Health Standards must include (but is not limited to):

  1. A copy of the investigation conducted by the hospital to include:
  2. The names, DOB, admission, discharge dates, and admission/pertinent diagnoses of all patients involved in the occurrence or in reporting the occurrence
  3. The name(s), title(s), and social security number(s) of the alleged perpetrator(s), as well as professionallicense numbers (if applicable)
  4. The date and time of the alleged event
  5. To whom (i.e. hospital personnel), and the date and time, the alleged event was initially reported, and the name(s) of witnesses, as applicable
  6. The date and time the first personnel aware of the event notified his/her supervisor
  7. The date and time that administration was notified
  8. The patient census on the unit or in the department at the time of the alleged event
  9. The number of patients that required special supervision or observation
  10. The type and number of staff members present on the unit or in the department at the time of the alleged event
  1. The observation status of the patient(s) listed in the allegation before and after the alleged incident (or discovery), as appropriate
  2. Transcripts or summaries of interviews conducted with staff members, patients, and anyone else, to include names/titles (of interviewer and interviewee), content of interview, and dates/times of interviews
  3. Interviews with alleged perpetrator(s) to include content of interview
    (including the alleged perpetrators responses), to include names/titles (of interviewer and interviewee), and date/time of interview(s)
  4. Summary of counseling and/or identified issues in the perpetrator’s HR file relative to patient care
  5. Description of relevant educational content (and dates provided) completed by the perpetrator prior to the alleged occurrence
  6. Documents supporting the validity, or lack thereof, of the allegation
  7. The conclusion reached by administration with regard to the allegation (i.e. substantiated, unsubstantiated, unable to substantiate)

Facility Investigation (Administrative Review) and Final Investigative Report (cont’d)

  1. A description of any policies, procedures, and practices employed by the facility to prevent occurrences of abuse/neglect either in accordance with regulations or as prescribed by the facility. Examples may include:
  2. Background checks on employees
  3. Pre-hire reference checks
  4. Orientation and training relevant to abuse/neglect and/or managing behavior
  5. Policies designed to create a protective environment for patients and staff (e.g. male staff members bathing female patients or providing perineal/cath care, etc.)
  6. Policies designed to restrict access or provide monitoring
  7. Policies that dictate frequency and/or nature of observation by nonlicensed and licensed personnel
  8. Policies designed to provide alternative measures if electronic devices (i.e. computers, call systems, etc.) fail or do not meet the needs of patients

NOTE: The above guidelines, (i.e. B: a-g) do not necessarily reflect processes, systems, or policies required by regulation or statute, nor are they all-inclusive. They are listed only to provide examples of policies and/or systems that facilities may have in place to prevent occurrences. The provider is encouraged to provide any and all documentation that demonstrates that the facility takes precautions to prevent abuse and/or neglect.

  1. A description of actions taken by the facility subsequent to the event to include:
  2. Actions taken to initially safeguard the patient(s) upon discovery of the incident
  3. To whom the facility reported the event (with dates, times and the name/title of the reporter) to include, as appropriate, law enforcement, family members, etc.
  4. Disciplinary/instructional actions with regard to the alleged perpetrator(s)
  5. Educational/training programs provided to staff members prior and subsequent to the event, to include content and attendees
  6. Whether the facility reported the event and alleged perpetrator(s) to their professional licensing board(s) or registry, as appropriate, and if so, the date and time of the report, the name of the agency or board, the name/title of the hospital representative that submitted the report and the name/title of the agency/board to whom the report was submitted
  7. Reviews, revisions, and/or initiation of policies and procedures made in connection to this occurrence (either prior or subsequent to the event)
  8. The role played by QA in tracking/trending such events; plans of correction initiated
  9. Copy of the signed written response the facility sends to the complainant (i.e. as indicated in policies and regulations regarding grievances)
  1. Special Settings and Considerations

This document describes the type of information needed by the Health Standards Section (HSS) to conduct a thorough review of a hospital’s actions in relation to an allegation that abuse and/or neglect has occurred within the facility involving hospital employees. In certain settings, including, but not limited to behavioral health facilities, pediatric units, and geriatric units, incidents involving physical or emotional abuse or sexual acting out between patients may be reportable, as the facility has specific responsibilities relative to providing adequate supervision to prevent these occurrences. Minors below the age of consent, psychiatric patients of any age, and cognitively impaired individuals (such as those with dementia or mental retardation) are not considered capable of consenting to sexual activity in a facility.As a result, sexual acts involving patients that fit these categories cannot be categorized as “consensual” even if both parties engage in the act voluntarily, and are reportable, as are occurrences indicating that the facility may have failed to adequately provide safety for the type of patient being treated.