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DDDDiiiivvvviiiissssiiiioooonnnnooooffffRRRReeeessssiiiiddddeeeennnnttttiiiiaaaallllSSSSeeeerrrrvvvviiiicccceeeessssNNNNYYYYSSSSDDDDeeeeppppaaaarrrrttttmmmmeeeennnnttttooooffffHHHHeeeeaaaalllltttthhhh
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EffectiveOctober17,2011,theprocessforfacilityreportingincidentstotheDepartmentofHealth(DOH)willchange.FacilitieswillcompletereportsviatheHealthCommerceSystem(HCS),usinganonlinereportversusutilizingtheHotlinetomakeareport.ReportswillbeaccessedbytheCentralizedComplaintIntakeUnit(CCIU),triagedandenteredintotheAspenComplaintTrackingSystem(ACTS)CaseResolutionUnit(CRU)staffwillreviewthecasetodetermineappropriateaction.Thirdpartycomplaintswillnotbeeffectedbythisprogram.
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FacilitieswillnolongercalltheNursingHomeComplaintHotline(unlesstheyareunabletoaccessthewebpage)
InformationonincidentswillbeobtainedbyCCIUaccessingthewebsite,andthenenteredintoACTS
DOHhascreatedadefinedlistofreportableincidents TheDepartmenthasdevelopedanonlinereferencemanual
forclarificationofreportableincidents Themanuallistselementsor relevantcomponents,thatif
present,rendertheincidentreportable
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Participantswill: Reviewthebasicprocessofinvestigatingfacilityincidents Gainanunderstandingoftheelectronicfacilityincident
reportingsystem Becomeacquaintedwiththeprocessofreportingincidentsvia
theHCS Gainawarenessofwhatconstitutesareportableincident.
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TheroleoftheDepartmentofHealth: DetermineREGULATORYcompliance.Determineifabuse,mistreatmentorneglecthas
occurredDetermineifqualityofcarewasachievedDeterminethataplantopreventrepeatoccurrences
wasdeveloped,communicatedandimplemented
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An
investigation
is
the
gathering
of
evidence
and/or
data
relatedtoanoccurrence,orincident. Thegoalistoarriveatalogicalconclusionbasedon the
evidence Facilityinvestigationsmustbeginimmediately,upon
discoveryofanincident
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Facilitiesarerequiredtoinvestigatethefollowing: Accidents Injuryofunknownorigin Abuse,mistreatment,neglect Misappropriationofproperty Complaintsrelatedtocare MedicationerrorsThisisnotanallinclusivelist.
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AAAABBBBUUUUSSSSEEEE Physical/sexualabusebystaff Physical/sexualabusebyresident Physical/sexualabusebyfamilyorvisitor Mistreatment Neglect Dignity/verbalormentalabuseCCCCAAAARRRREEEEPPPPLLLLAAAANNNNVVVVIIIIOOOOLLLLAAAATTTTIIIIOOOONNNNSSSS Failuretofollowcareplanwithinjury Failuretofollowcareplanwithoutinjury
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RRRReeeeppppoooorrrrttttaaaabbbblllleeeeOOOOccccccccuuuurrrrrrrreeeennnncccceeeessssCCCCoooonnnnttttiiiinnnnuuuueeeedddd
RRRRE
EEES
SSSI
IIIDDDDE
EEEN
NNNT
TTTP
PPPR
RRRO
OOOP
PPPE
EEER
RRRT
TTTY
YYY
MisappropriationofpropertyQQQQUUUUAAAALLLLIIIITTTTYYYYOOOOFFFFCCCCAAAARRRREEEE Medicationerrorwithharm/drugdiversion Deathrelatedtosuicide,restraints,equipment CPRissues Attemptedsuicide Injuryofunknownorigin
Burns
Accidentsrelatedtochoking Accidentsrelatedtoentrapment Residentfoundinnon-residentarea(basement,stairwell,etc)
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RRRReeeeppppoooorrrrttttaaaabbbblllleeeeOOOOccccccccuuuurrrrrrrreeeennnncccceeeessssCCCCoooonnnnttttiiiinnnnuuuueeeeddddEEEELLLLOOOOPPPPEEEEMMMMEEEENNNNTTTT Elopementoccurswhenaresidentleavesthebuilding
undetectedorfailstoreturnfromapreauthorizedleaveofabsence
PPPPHHHHYYYYSSSSIIIICCCCAAAALLLLEEEENNNNVVVVIIIIRRRROOOONNNNMMMMEEEENNNNTTTT Fires/smoke Faultyequipment
Physicalplant
issues
Power,water,electricaloutagesoranyinterruptionof
service
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CanbeaccessedonlineontheHCS Containsrelevantinformationforeachreportableincident. Guidesinvestigationbythefacility,andlistsmaterialsthat
thefacilityshouldhaveavailabletosurveyors. Themanual listselementsor relevantcomponents,thatif
present,rendertheincidentreportable.
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TTTThhhheeeemmmmaaaannnnuuuuaaaallll aaaallllssssooooccccoooonnnnttttaaaaiiiinnnnssss::::Aquestionandanswersectiononbothgeneralmattersandonspecificreportingcategories((((TTTThhhheeeeqqqquuuueeeessssttttiiiioooonnnnssssaaaannnnddddaaaannnnsssswwwweeeerrrrsssspppprrrroooovvvviiiiddddeeeeeeeexxxxaaaammmmpppplllleeeessssaaaannnnddddddddoooonnnnoooottttccccoooovvvveeeerrrraaaallllllllssssiiiittttuuuuaaaattttiiiioooonnnnssss))))Thefacilityrequirementsconcerningtimelyreportingofoccurrences,includingFailuretoReportGuidelinesforeachreportableincidentDocumentsthatshouldbemaintainedwiththefacilityinvestigation
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Thepresenceofelementsdeterminesiftheincidentisreportable
to
DOH
FOREXAMPLE: physicalabuse
Two(2)ofthefollowingelementsareneededforanincidentofabusetobereportedtoDOH: IntentORrecklesslyperformanact Bodilyinjuryand/orseriousbodilyinjury Inappropriatephysicalcontact Repeatedincidentsofresidenttoresidentabuse
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Themanualprovidesguidelinesastorequireddocumentstobeusedduringandmaintainedaftertheinvestigation.Example: PhysicalabuseInvestigationmaterials: Completeelectronicincidentform Haveavailable
Witnessstatement(s) Residentstatement(s) Accusedstatement(s) Photographicevidence(ifavailable) Facilityinvestigation Careplan(s)
Residentcognition
evaluation
Employeepersonnelandtrainingrecords Plantopreventreoccurrence
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Themanualaddressesreportableincidentsasfollows: Topic Regulatoryreference
Elements
Guidanceoninvestigationmaterialstogatherandhaveavailabletothesurveyor
Q&ArelatedtoNHscenarios
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ReportsmustbemadetotheDepartmentofHealthiiiimmmmmmmmeeeeddddiiiiaaaatttteeeellllyyyyuponachievingtheRRRREEEEAAAASSSSOOOONNNNAAAABBBBLLLLEEEECCCCAAAAUUUUSSSSEEEEthreshold,revealingthat misappropriationofproperty,abuse,mistreatmentorneglectoccurred
Immediateisdefinedasassoonaspossible,nottoexceed24hours
Reasonablecauseisdefinedtomeanthatuponareviewofthecircumstances,thereissufficientevidenceforaprudentpersontobelievethatphysicalabuse,mistreatmentorneglecthasoccurred
ReportsmustbemadetotheDOHwhenthereasonablecausethresholdhasbeenachieved,revealingabuse,mistreatmentorneglect
FFFFaaaacccciiiilllliiiittttyyyyiiiissssttttoooonnnnoooottttiiiiffffyyyyDDDDOOOOHHHHwwwwhhhheeeennnntttthhhheeeeyyyyhhhhaaaavvvveeeerrrreeeeaaaacccchhhheeeeddddrrrreeeeaaaassssoooonnnnaaaabbbblllleeeeccccaaaauuuusssseeee,,,,aaaannnnddddtttthhhheeeennnnhhhhaaaavvvveeee5555wwwwoooorrrrkkkkiiiinnnnggggddddaaaayyyyssssttttoooocomplete the investigation.complete the investigation.complete the investigation.completetheinvestigation.
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Abusehasnotbeenruledout(especiallywithinjuriesofunknownorigin)
Facilityinvestigationisinconclusive Staffstatementsareofpoorqualitynotsignedordated,no
title,lackpertinentinformation Careplanwasnotappropriatetoresidentsindividualneeds
(Forexample,thecareplanwasnotchangedtoreflectresidentschangeincondition)
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Concerns Identified DuringDOH Investigation
Residenthasahistoryofincidentsbutthecareplanfailstoreflectthoseoccurrences
Incidentsaredocumentedonacareplanwithoutinterventionsoraplantopreventrecurrence
Staffisunawareof changestotheplanofcare.Forexample,theCNAcarddoesnotmatchPOC
Careplanisnotalignedwithresidentsneeds.Forexample,careplanlistsanapproachofremindersnottostandbutresidenthasdementiaandcannotremember
Unrealisticgoalsandinterventionsarecareplanned
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Departmentstaffhasexplicitauthoritytoinspectthefacility,interviewpatientsorresidents,reviewrelevantrecords,observecarebeingprovidedandconductnecessaryinterviews.LLLLiiiicccceeeennnnsssseeeeddddffffaaaacccciiiilllliiiittttiiiieeeessssmmmmaaaayyyynnnnoooottttrrrreeeeqqqquuuuiiiirrrreeeetttthhhheeeeDDDDeeeeppppaaaarrrrttttmmmmeeeennnnttttttttoooommmmaaaakkkkeeeeaaaannnnaaaappppppppooooiiiinnnnttttmmmmeeeennnnttttaaaannnnddddmmmmaaaayyyynnnnoooottttddddeeeellllaaaayyyyaaaannnniiiinnnnssssppppeeeeccccttttiiiioooonnnn
OurfederalinvestigationactivitiesareguidedbytheStateOperationsManual(SOM)andrelatedAppendices
TheSOMspecificallyrecognizesthattttthhhheeeeddddeeeecccciiiissssiiiioooonnnnttttooooppppeeeerrrrmmmmiiiittttoooorrrrddddeeeennnnyyyyffffaaaacccciiiilllliiiittttyyyyppppeeeerrrrssssoooonnnnnnnneeeelllliiiinnnnvvvvoooollllvvvveeeemmmmeeeennnnttttdddduuuurrrriiiinnnnggggtttthhhheeeessssuuuurrrrvvvveeeeyyyypppprrrroooocccceeeessssssssiiiissssssssoooolllleeeellllyyyytttthhhhaaaattttoooofffftttthhhheeeessssuuuurrrrvvvveeeeyyyyoooorrrr
TheSOMfurthernotesthatrefusalofaccesscanbeabasisforterminationfromtheparticipationintheMedicareandMedicaidprograms
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TheinvestigationlllleeeeaaaaddddssssyyyyoooouuuuttttooooddddeeeecccciiiiddddeeeewhetherornottoreporttheissuetotheDepartmentthroughtheHealthCommerce
System,
Incident
Reporting
Form
Iftheinvestigationwasthoroughandindicatesthat
aaaabbbbuuuusssseeee,,,,nnnneeeegggglllleeeecccctttt,,,,mmmmiiiissssttttrrrreeeeaaaattttmmmmeeeennnnttttoooorrrrmmmmiiiissssaaaapppppppprrrroooopppprrrriiiiaaaattttiiiioooonnnnooooccccccccuuuurrrrrrrreeeedddd,,,,tttthhhheeeennnniiiittttiiiissssaaaarrrreeeeppppoooorrrrttttaaaabbbblllleeeeiiiinnnncccciiiiddddeeeennnntttt
Iftheinvestigationwasthoroughandooooffffffffeeeerrrrssssnnnnooooeeeevvvviiiiddddeeeennnncccceeeeooooffffaaaabbbbuuuusssseeee,,,,mmmmiiiissssttttrrrreeeeaaaattttmmmmeeeennnntttt,,,,nnnneeeegggglllleeeeccccttttoooorrrrmmmmiiiissssaaaapppppppprrrroooopppprrrriiiiaaaattttiiiioooonnnn,,,,yyyyoooouuuuccccaaaannnnbbbbeeeejjjjuuuussssttttiiiiffffiiiieeeeddddiiiinnnnnnnnoooottttrrrreeeeppppoooorrrrttttiiiinnnnggggiiiittttttttooootttthhhheeeeHHHHoooottttlllliiiinnnneeee,,,,aaaannnnddddccccaaaannnnnnnnoooottttbbbbeeeecccciiiitttteeeeddddffffoooorrrrffffaaaaiiiilllluuuurrrreeeettttoooorrrreeeeppppoooorrrrtttt
Inaddition,someincidentsarereportableunderanycircumstances,iftherequiredelementsarepresent
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Thefacilitycanbecitedforfailuretocompleteathoroughinvestigation(Ftag225)if: Thesurveyorfindsthattheinvestigationfailedtocometoa
reasonableconclusion Thefacility failedtoinvestigatetheincident Thefacilitycanbecitedforfailuretocompleteathorough
investigation(Ftag225) Ifitwasdeterminedthatabuse,mistreatmentorneglect,or
misappropriationof
property
occurred
and
not
reported
to
DOH,
thentheycanbecitedforfailuretoreport
AnycrimemustbereportedtolawenforcementundertheElderJusticeLaw.Section1150BoftheSocialSecurityAct(theAct)asestablishedbysection6103(b)(3)ofthePatientProtectionandAffordableCareAct(AffordableCareAct),requiresspecificindividuals
in
long
term
care
facilities
to
report
a
reasonable
suspicionofcrimescommittedagainstaresident. ThosereportsmustbesubmittedtoonelawenforcementagencyofjurisdictionandtheStateSurveyAgency(SA).
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Toreportadditionalinformationtoanexistingcase: ContacttheCentralizedComplaintIntakeUnit
directlyat1888-201-4563,or Emailtheintakehotlineat
NHIntake@health.state.ny.us
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TheDOHhasdevelopedanelectronicincidentreportingsystem,whichwillallownursinghomestoreporttheirincidentsthroughtheHCS
Thenewformwillreplacetheprevioustelephonehotlinemethodforreportingincidents
EffectiveOctober17,2011FacilitieswillberequiredtoreportincidentsviathenewIncidentReportingFormavailableontheHCS
TheDepartmenthasprovidedanIncidentReportingManualtoclarifythereportingrequirements,andhelpensurethatfacilitiesarereportingincidentsrequiredunderStateandFederalstatutesandregulations
Themanual
provides
a
list
of
reportable
incidents
that
shallbereportedviatheHCS
TheDepartmentsrequirementsforreportingincidentsareconsistentwithpastreportingrequirements
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ThisPowerPointpresentationhasbeenpreparedtoassistproviderstocompletethoroughinvestigationandtopreparenursinghomeemployeesabouttheprocessforinvestigatingincidents,andwhatconstitutesareportableincident. ThispresentationisavailableonlineforfutureviewingAQuestionandAnswersessionwillbescheduledwiththeProviderAssociations.TheIncidentReportingForm,PowerPointPresentation,andIncidentReportingManualwillbepostedontheDOHwebsitewithintheDearAdministratorLettersection.
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Reportingmechanism: https://commerce.health.state.ny.us TheformerIncidentReportingLinephonenumber,1-888-
201-4563,maybeusedincaseofanemergencysuchasyourInternetorcomputersaredown
Detailedinstructionmanualisavailableatthewebsite
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Iffacilitystaffhavequestionsonthisprocess,oronreportableincidents,pleasecontact:
Theintakehotlineat1-888-201-4563,or EmailtheIntakemailboxat
Nhintake@health.state.ny.us,or ContactMarkBrownell,AssistantDirectorof
theBureauofComplaintsandAnalysisorJoanneBreden,Supervisor, at518-402-5447
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Todetermineifabuse,mistreatment,neglectormisappropriation occurred
Toassurecompliancewithstatutesandregulations Toimprovequalityofcare Toidentifyflawedpractices/policy Toidentifyandcorrectvulnerabilities Toassistwithmanagementofrisk
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Theinvestigationshouldassistthefacilityindeterminingiftheconcernwasaresultof:
Individual(s)action
(staff
member
acted
on
their
own,
outside
ofpolicy)
Facilitypractice(flawedpracticeorpolicy)Didabuse,mistreatment,neglectormisappropriationofpropertyoccur? Theinvestigationshouldruleoutorconfirmabuse,
mistreatmentorneglectthroughareviewofsupportingevidence,includinginterviewsandstatementsthatoffervalidinformation,observationsandrecordreview
Theoutcomeisdeterminedbyfacts,basedontheevidenceandnotanopinionwhichissubjective
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IIIInnnntttteeeerrrrvvvviiiieeeewwww
OOOObbbbsssseeeerrrrvvvvaaaattttiiiioooonnnnRRRReeeeccccoooorrrrddddRRRReeeevvvviiiieeeewwww
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INTERVIEW:Obtainingstatementfrompartiesdirectlyinvolvedandotherspossessingknowledgeofrelevantinformation.Thismay
include
staff,
residents
and
third
party
OBSERVATION:ofthesurroundingsorscenewheretheincidentisallegedtohaveoccurred.ObservationofthegeneralcareandconditionoftheareaisveryimportantRECORDREVIEW: reviewofmedicalrecords,careplan,anyrelateddocuments
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Renderaidtopppprrrrooootttteeeecccctttttheresidents,removingthemfromharm
Protectthescene.preserveanyphysicalevidence Collectevidence(askwho,what,when,whereandhow) Determinepresenceofintentbyaggressor Determineyourwitnesses Conductinterviews Documentation(incidentreporting form,medicalrecords,
interviewstatements) Determineifabuse,neglectormistreatmenthasoccurred Documentyourconclusions
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CONSIDERTHEFOLLOWING: Withallegationsofabusemistreatmentorneglect:tryto
leavearea
untouched,
as
much
as
possible
Preserveanyevidence/photographs(photosmustbe
dated,timedandabletocorrectlyidentifythesubject) Makenoteofresidentconditionandenvironmental
conditions Staffobservation Circumstancesjustpriortotheeventordiscovery Evidenceis:Anythingthatwillhelpreconstructthe
incident,identifypeopleinvolvedand/oridentifytheresponsiblepersons
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Obtainingstatementfrompartiesdirectlyinvolvedandotherspossessinginformation
Anon-accusatoryprocessinwhichtheinterviewerasksquestionsdesignedtodevelopfactualinformation
Documentationmustbesigned,datedandshouldincludetheindividualstitle
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Who,what,where,when,whyandhow?Maintainalistofthequestionsposedtothe individualsbeinginterviewedObtainstatementfromtheresident(s),iftheyareabletoprovideastatementabouttheincident,wheneverpossible
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Takenotesduringtheinterview Provideprivacy,minimizedistractions;listencarefullyandbepatient Whatdoesstaffsay Areyouinterviewingthemordotheyfilloutaform Whatkindofquestionsareyouaskingstaff Questionsshouldbeopenended,designedtoelicit
descriptionsofobservations, interventions,orre-enactments
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ItfrequentlyisnotenoughtohavestaffwritewhattheyknowDiscussions,includingthefollowingmaybemoreinformative. Describeinteractionwithresident Physicaldemonstrationofcaredelivered Didyouseeanyonephysicallyharmresident Describeforceused,stanceofaccusedandanyinjury Didyoucheckthechairalarm Wasitworking DidyouseeSallyusethegaitbelt Whatcantheresidentdoindependently Whatdidthecareplanrequire
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Writtenstatementsareusuallyneededfromtheaccused,andfromwitnesses.Additionalstaffstatementsmaybenecessarytodeterminewhatcarewasdelivered. Wasthecareprovidedinaccordancewiththeindividualizedplanofcare.Writtenstatementswillneedtobeobtainedinadditiontotheinterviews.
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Writtenstatementsshouldbe: Legible Signed,dated,andindicateshiftandjobtitle Thepreferenceistohaveindividualwritetheirown
statement,butiftheyareunable,thewritershouldobtainsignatureofindividualorhaveitwitnessed
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Whatdidyousee Whatdidotherssee Whatdoestheenvironmenttellyou Isthereevidencethatthecareplanwasfollowed Whatdoyouseewhenyoulookatorspeaktootherresidents Whatdoyouhearwhenwalkingthroughtheunit Doyouseeevidenceofpotentialabuseorconcern
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Whatwasrequiredbycareplan Wasitanappropriateindividualizedplanofcare Whataretheresidentsriskfactors AretheriskfactorsidentifiedinthePlanofCare Wasthecareplanfollowed Whatwasdocumentedupondiscoveryofevent Whatdonursesreportsindicate WereMDordersfollowed WastheCNArecordcompletedaccurately Werefacilitypoliciesandproceduresfollowed
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Doesthecareplanneedtobeupdatedtopreventrecurrence Isanythinggoingonmedicallythatsbeenmissed (UTI? URI?
Labs?)
Whatistheresidentshistory Whatistheresidentsbehavior Doesthecareplanreflectactualcareneeded DoesCNAcareplanmatchthecomprehensivecareplan DoestheCNAcareplangivespecificinformationtothestaff
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Isthereastaffmemberinvolved Whatisthestaffmembersperformancehistory Hasthestaffmember beencounseledforcareissuesorfailuretofollowthecareplaninthepast Wascareappropriatelydocumented Doesthisindicatethatthecareplanwasfollowed Hasthestaffmemberbeeneducatedortrainedintheareabeinginvestigated,andnotedinthepersonnelrecords
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Allevidenceusedtodeterminetheoutcomeoftheinvestigation
should
be
relevant
to
the
case
Ifthecaseisrelatedtoamedicationisahardcopyofthe
properMedicationAdministrationRecordinthecasefile Ifthecaseisrelatedtoacareplanviolation,isthecareplan
inthecasefile Allmaterialsrelevanttotheoutcomeshouldbeincludedin
thefile
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Whatisathoroughinvestigation Onethatcomestoareasonableconclusionastohowand/orwhysomethingoccurred Theinvestigationshouldruleoutorconfirmabuse,
mistreatmentorneglectbyreviewofsupportingevidence,includinginterviewsandstatementsthatoffervalidinformation,observationsandrecordreview
Theoutcomeisdeterminedbyfact,basedontheevidenceandnotonopinion
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Uponreviewingalloftheevidence,aconclusionisdetermined. Didabuse,mistreatmentorneglectoccur Isthereapolicyorpracticeissuethatcausedrisk Isthisanisolatedincidentorasystemicproblem Doestheevidencesupporttheoutcome
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Immediately,take correctiveactionincludingeducation Identifytrends ImplementandcommunicateQIinterventionsforlong
termpreventionofrecurrenceofthematter PeriodicallyreviewandreviseinterventionsReportto appropriateagencyasnecessary: Ifabuse,mistreatment,neglectormisappropriation,
contactlawenforcement Ifaprofessionalissue,contactStateEducationorDOH
OfficeofProfessionalMisconduct(OPMC) Ifcontrolledsubstanceissue,contacttheDOHBureauof
NarcoticEnforcement(BNE)47
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