Reporting All Allegations of Mistreatment, Neglect,
Abuse and Injuries of Unknown Source Immediately to Administrator as
Required at 42 CFR 483.420(d)(2) – (W Tag 153)
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Date: January 12, 2004 DDES-BQA-04-002
To: Facilities Serving People with Developmental Disabilities FDD
02
From: Michael Steinhauer, Chief, Resident Care and Review Section
Via: Susan Schroeder, Director, Bureau of Quality Assurance
Federal Monitoring Surveys (FMS) in Intermediate Care Facilities
serving persons with Mental Retardation (ICF/MR) have identified an
emerging issue related to the Code
of Federal Regulation (exit DHFS) 42 CFR 483.420(d)(2). BQA is sending this memo
to clarify the requirement at W153 as specified by the federal Centers for
Medicare & Medicaid Services (CMS).
42 CFR 483.420(d)(2) requires the following:
- The facility must ensure that all allegations of mistreatment,
neglect or abuse, as well as injuries of unknown source, are to be
reported immediately to the Administrator or to other officials in
accordance with State law through established procedures.
CMS provides verbal guidance that there are three key areas within W
tag 153.
- All allegations of mistreatment, neglect, abuse and injuries of
unknown source must be reported immediately to assure
prompt detection
- All allegations of mistreatment, neglect, abuse and injuries of
unknown source must be reported to the administrator and cannot be
delegated to other staff
- Reporting must be done via a "reproducible mechanism" (CMS
term taken from State Operations
Manual
(exit DHFS)
Transmittal 278 TASK 2 page J-9.)
The regulation requires immediate reporting. By immediate reporting, it
is expected that any allegation of mistreatment, neglect, abuse and
injuries of unknown source is reported as soon as staff becomes aware of
the incident. This does not allow for delay based on the time of the day
or night or convenience of staff. Injuries of unknown source discovered
when the administrator is not in-house would require immediate
notification to the administrator. The injury must be reported
immediately, regardless of the size of the facility, how minor the
incident or the number of allegations.
The requirement to report directly to the administrator does not allow
for delegation to an alternate staff member. Facility policy should
specify who has the authority of the administrator when the administrator
is unable to assume his/her functions. During these times, the
administrator may appoint an acting administrator who has full authority
to take prompt and necessary action to assure health and safety of clients
(including termination of employees). The administrator or acting
administrator with full authority is responsible to receive and act on
reports of allegations 24 hours every day.
A "reproducible mechanism" would show evidence of the
administrator being notified that corresponds to a written signature with
time and date. According to CMS, sending an e-mail or voice mail does not
meet the intent of this regulation. Though these methods may be
reproducible, they do not ensure the administrator received the
information in a timely manner.
The above clarification and guidance does not reflect a change in the
federal regulations. It is a CMS clarification of the intent of the
regulations. The intent is to ensure that there is an effective system in
place to protect clients from abuse and neglect. Staff must understand and
practice the procedures used to report all allegations of mistreatment,
neglect, abuse and injuries of unknown source as required.
BQA encourages prompt review of your reporting process. Failure to
comply with each and all of the above components each and every time will
result in a citation of W tag 153 and possibly other related W tags.
If you have further questions about reporting requirements, please
contact the BQA Regional Field Operations Director in your
area, Jean
Kollasch, BQA Provider Regulation Consultant at (608) 267-0466 or Dinh
Tran, BQA Social Services Consultant at (608) 266-6646.
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