ANE
Abuse, Neglect and Exploitation Policy It is the policy of the company to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident property, and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown origin and misappropriation of resident property ("alleged violations"), are reported immediately to the Administrator. Violations will also be reported to state agencies in accordance with existing state law. The Administrator will direct a thorough investigation of each such alleged violation unless there is a conflict of interest or the Administrator is implicated in the alleged violation. The Administrator is responsible is for reporting the results of all investigations to the state agencies as required by state and federal law. Please note, social media posting by an employee, visitor or family member may be considered abuse as it has the potential to violate the resident’s right to privacy. Social media posts by employees will be investigated as allegations of abuse with all the potential consequences set forth in the discipline policy. Employees are not allowed to use cell phones or any other digital device to record the resident’s likeness in any manner without the written consent of the resident and/or power of attorney. Application All Employees Procedure The company shall take the following steps to prevent, detect and report abuse, neglect, Injuries of unknown origin and the misappropriation of resident property. Screening All applicants for employment in the Company shall, at a minimum, have the following screening checks conducted: 1. Reference checks with the current and/or past employer. 2. Appropriate licensing board or registry check. 3. Criminal background check pursuant to Company policy or state law. The DON, or Human Resources is responsible for the initial licensing and/or registry check, The Administrator or Human Resources must ensure that all screening is completed. No applicant shall be considered for employment unless all screenings are completed, and the applicant’s license is unrestricted.
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Abuse, Neglect and Exploitation Training During orientation, all new employees shall be trained on the procedures to report alleged violations. Training shall include definitions of alleged violations and examples of reportable incidents to assist staff in detection of such incidents. Training shall include appropriate interventions to deal with aggressive and/or catastrophic reactions of residents and caregiver stress. Training for volunteers shall take place during orientation. Each employee shall receive annual training on the requirements of the policies and procedures regarding alleged violations and the requirements of state and federal law. Prevention Staff, families and employees are required to report ALL incidents of suspected abuse, neglect or misappropriation of resident property without fear of reprisal. Families, residents and volunteers shall be encouraged to report incidents of suspected abuse, neglect, or misappropriation of resident property without fear of reprisal. The Administrator shall identify, intervene and correct situations in which abuse, neglect, or exploitation of resident property are more likely to occur. All other staff is required to report such potential situations to the Administrator as soon as identified. Identification Reporting of suspected alleged violations is required of every employee. Incidents of alleged violations shall be reviewed by the QAPI team for detection of patterns or trends. Protections If the circumstances require it, the DON or Administrator shall remove a resident suspected of being the subject of an alleged violation to an environment where the resident's safety can be protected. If the suspected perpetrator is another resident, the DNS or ED/DOR shall separate the residents so they do not have access to each other until the circumstances of the alleged incident can be determined. If the suspected perpetrator is an employee, the Administrator shall place the employee on immediate investigatory suspension while completing the investigation. It should be explained to the employee that if the conclusions of the investigation do not require additional suspension or termination, the employee may be allowed to return to work. Any scheduled days missed during the suspension time may be paid if there is no disciplinary action issued. Where the circumstances of the alleged violation warrant, the DON shall initiate a physical and mental assessment of the resident and document the findings. Factual information only shall be documented, not assumptions or conclusions.
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Abuse, Neglect and Exploitation If the suspected perpetrator is a vendor, visitor, or volunteer the Administrator shall take all appropriate measures immediately to secure the safety and wellbeing of the resident. Said measures may include disallowing contact between the resident and alleged perpetrator while an investigation is conducted.
Reporting Any employee who suspects an alleged violation shall immediately notify the Administrator. The Administrator shall notify the appropriate state agency, in accordance with state law, as well as notify immediate management. The DON, or appropriate clinician, shall also notify the attending physician regarding the alleged violation and findings and document the contact. The DON shall notify the resident's representative regarding the alleged violation and assessment findings and reassure the resident's representative that an investigation has been initiated and appropriate action will be taken. This contact shall be documented. Investigation All investigations shall be conducted by the Administrator or subject matter expert, unless there is a conflict of interest or they are implicated in the alleged violations. In the event an alleged violation occurs when none of these people are available, the manager in charge is responsible for initiating the investigation procedure unless there is a conflict of interest or the person is implicated in the alleged violations. The investigation shall include interviews of employees, visitors, residents, volunteers and vendors who may have knowledge of the alleged incident. Factual information only should be documented, not assumptions, speculation, or conclusions. Written statements from involved parties should not be requested as all information will be documented on the Verification of Investigation form or a state required form. The documentation of the investigation shall be kept in the Administrator's office in a secure administrative file. Investigatory notes or other documentation gathered during the investigation should not be placed in employee personnel files. The medical record should be reviewed to determine the resident's past history and condition and its relevance to the alleged violation. Federal law requires the facility to have evidence of investigations of alleged violations. The "Verification of Investigation" or state required form shall be completed after the investigation is complete and provided to survey agencies when requested or required by state or federal law. This form shall be maintained in the Administrator’s office in a secure administrative file. It is not part of the medical record.
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Abuse, Neglect and Exploitation
Corrective Action The facility shall make reasonable efforts to determine the cause of the alleged violation and take corrective action consistent with the investigation findings and to eliminate any ongoing dangers to the resident. The DON, in conjunction with other clinicians, shall initiate or revise a care plan to reflect the resident's condition and measures to be taken to prevent recurrence, where appropriate. Appropriate steps shall be taken to prevent recurrence of the incident. This may include inservices or other measures as appropriate. The steps taken should be documented. Documentation All alleged violations shall be recorded on the Verification of Investigation form or the required investigation form for reporting to government agencies. Copies of this form shall be kept in the center/location. Documentation in the medical record shall be made where necessary for continuity of care for the resident. Separate incident reports or other written reports, when required by state law, shall be maintained and produced in accordance with state law.
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Abuse, Neglect and Exploitation Training During orientation, all new employees shall be trained on the procedures to report alleged violations. Training shall include definitions of alleged violations and examples of reportable incidents to assist staff in detection of such incidents. Training shall include appropriate interventions to deal with aggressive and/or catastrophic reactions of residents and caregiver stress. Training for volunteers shall take place during orientation. Each employee shall receive annual training on the requirements of the policies and procedures regarding alleged violations and the requirements of state and federal law. Prevention Staff, families and employees are required to report ALL incidents of suspected abuse, neglect or misappropriation of resident property without fear of reprisal. Families, residents and volunteers shall be encouraged to report incidents of suspected abuse, neglect, or misappropriation of resident property without fear of reprisal. The Administrator shall identify, intervene and correct situations in which abuse, neglect, or exploitation of resident property are more likely to occur. All other staff is required to report such potential situations to the Administrator as soon as identified. Identification Reporting of suspected alleged violations is required of every employee. Incidents of alleged violations shall be reviewed by the QAPI team for detection of patterns or trends. Protections If the circumstances require it, the DON or Administrator shall remove a resident suspected of being the subject of an alleged violation to an environment where the resident's safety can be protected. If the suspected perpetrator is another resident, the DNS or ED/DOR shall separate the residents so they do not have access to each other until the circumstances of the alleged incident can be determined. If the suspected perpetrator is an employee, the Administrator shall place the employee on immediate investigatory suspension while completing the investigation. It should be explained to the employee that if the conclusions of the investigation do not require additional suspension or termination, the employee may be allowed to return to work. Any scheduled days missed during the suspension time may be paid if there is no disciplinary action issued. Where the circumstances of the alleged violation warrant, the DON shall initiate a physical and mental assessment of the resident and document the findings. Factual information only shall be documented, not assumptions or conclusions.
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Abuse, Neglect and Exploitation If the suspected perpetrator is a vendor, visitor, or volunteer the Administrator shall take all appropriate measures immediately to secure the safety and wellbeing of the resident. Said measures may include disallowing contact between the resident and alleged perpetrator while an investigation is conducted.
Reporting Any employee who suspects an alleged violation shall immediately notify the Administrator. The Administrator shall notify the appropriate state agency, in accordance with state law, as well as notify immediate management. The DON, or appropriate clinician, shall also notify the attending physician regarding the alleged violation and findings and document the contact. The DON shall notify the resident's representative regarding the alleged violation and assessment findings and reassure the resident's representative that an investigation has been initiated and appropriate action will be taken. This contact shall be documented. Investigation All investigations shall be conducted by the Administrator or subject matter expert, unless there is a conflict of interest or they are implicated in the alleged violations. In the event an alleged violation occurs when none of these people are available, the manager in charge is responsible for initiating the investigation procedure unless there is a conflict of interest or the person is implicated in the alleged violations. The investigation shall include interviews of employees, visitors, residents, volunteers and vendors who may have knowledge of the alleged incident. Factual information only should be documented, not assumptions, speculation, or conclusions. Written statements from involved parties should not be requested as all information will be documented on the Verification of Investigation form or a state required form. The documentation of the investigation shall be kept in the Administrator's office in a secure administrative file. Investigatory notes or other documentation gathered during the investigation should not be placed in employee personnel files. The medical record should be reviewed to determine the resident's past history and condition and its relevance to the alleged violation. Federal law requires the facility to have evidence of investigations of alleged violations. The "Verification of Investigation" or state required form shall be completed after the investigation is complete and provided to survey agencies when requested or required by state or federal law. This form shall be maintained in the Administrator’s office in a secure administrative file. It is not part of the medical record.
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Abuse, Neglect and Exploitation
Corrective Action The facility shall make reasonable efforts to determine the cause of the alleged violation and take corrective action consistent with the investigation findings and to eliminate any ongoing dangers to the resident. The DON, in conjunction with other clinicians, shall initiate or revise a care plan to reflect the resident's condition and measures to be taken to prevent recurrence, where appropriate. Appropriate steps shall be taken to prevent recurrence of the incident. This may include inservices or other measures as appropriate. The steps taken should be documented. Documentation All alleged violations shall be recorded on the Verification of Investigation form or the required investigation form for reporting to government agencies. Copies of this form shall be kept in the center/location. Documentation in the medical record shall be made where necessary for continuity of care for the resident. Separate incident reports or other written reports, when required by state law, shall be maintained and produced in accordance with state law.
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