DivisionofResidentialServices

NYSDepartmentofHealth

EffectiveOctober17,2011,theprocessforfacilityreporting
incidentstotheDepartmentofHealth(DOH)willchange.
FacilitieswillcompletereportsviatheHealthCommerceSystem
(HCS),usinganonlinereport versusutilizingtheHotlinetomakea
report.
ReportswillbeaccessedbytheCentralizedComplaintIntakeUnit
(CCIU),triagedandenteredintotheAspenComplaintTracking
System(ACTS)
CaseResolutionUnit(CRU)staffwillreviewthecasetodetermine
appropriateaction.
Thirdpartycomplaintswillnotbeeffectedbythisprogram.

FacilitieswillnolongercalltheNursingHomeComplaint
Hotline(unlesstheyareunabletoaccessthewebpage)
InformationonincidentswillbeobtainedbyCCIUaccessing
thewebsite,andthenenteredintoACTS
DOHhascreatedadefinedlistofreportableincidents
TheDepartmenthasdevelopedanonlinereferencemanual
forclarificationofreportableincidents
Themanuallistselementsorrelevantcomponents,thatif
present,rendertheincidentreportable

Participantswill:

Reviewthebasicprocessofinvestigatingfacilityincidents
Gainanunderstandingoftheelectronicfacilityincident
reportingsystem
Becomeacquaintedwiththeprocessofreportingincidentsvia
theHCS
Gainawarenessofwhatconstitutesareportableincident.

TheroleoftheDepartmentofHealth:
DetermineREGULATORYcompliance.
Determineifabuse,mistreatmentorneglecthas
occurred
Determineifqualityofcarewasachieved
Determinethataplantopreventrepeatoccurrences
wasdeveloped,communicatedandimplemented

Aninvestigationisthegatheringofevidenceand/ordata
relatedtoanoccurrence,orincident.

Thegoalistoarriveatalogicalconclusionbasedon the
evidence
Facilityinvestigationsmustbeginimmediately,upon
discoveryofanincident

Facilitiesarerequiredtoinvestigatethefollowing:

Accidents
Injuryofunknownorigin
Abuse,mistreatment,neglect
Misappropriationofproperty
Complaintsrelatedtocare
Medicationerrors

Thisisnotanallinclusivelist.

ABUSE
Physical/sexualabusebystaff
Physical/sexualabusebyresident
Physical/sexualabusebyfamilyorvisitor
Mistreatment
Neglect
Dignity/verbalormentalabuse
CAREPLANVIOLATIONS
Failuretofollowcareplanwithinjury
Failuretofollowcareplanwithoutinjury

ReportableOccurrences

Continued

RESIDENTPROPERTY
Misappropriationofproperty
QUALITYOFCARE
Medicationerrorwithharm/drugdiversion
Deathrelatedtosuicide,restraints,equipment

CPRissues
Attemptedsuicide
Injuryofunknownorigin
Burns
Accidentsrelatedtochoking
Accidentsrelatedtoentrapment
Residentfoundinnonresidentarea(basement,stairwell,etc)
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ReportableOccurrences

Continued

ELOPEMENT
Elopementoccurswhenaresidentleavesthebuilding
undetectedorfailstoreturnfromapreauthorized
leaveofabsence
PHYSICALENVIRONMENT
Fires/smoke
Faultyequipment
Physicalplantissues
Power,water,electricaloutagesoranyinterruptionof
service

10

CanbeaccessedonlineontheHCS
Containsrelevantinformationforeachreportableincident.
Guidesinvestigationbythefacility,andlistsmaterialsthat
thefacilityshouldhaveavailabletosurveyors.
Themanual listselementsorrelevantcomponents,thatif
present,rendertheincidentreportable.

11

Themanualalsocontains:
Aquestionandanswersectiononbothgeneralmattersandon
specificreportingcategories(Thequestionsandanswers
provideexamplesanddonotcoverallsituations)
Thefacilityrequirementsconcerningtimelyreportingof
occurrences,includingFailuretoReport
Guidelinesforeachreportableincident
Documentsthatshouldbemaintainedwiththefacility
investigation

12

Thepresenceofelementsdeterminesiftheincidentis
reportabletoDOH
FOREXAMPLE:physicalabuse
Two(2)ofthefollowingelementsareneededforan
incidentofabusetobereportedtoDOH:
IntentORrecklesslyperformanact
Bodilyinjuryand/orseriousbodilyinjury
Inappropriatephysicalcontact
Repeatedincidentsofresidenttoresidentabuse

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Themanualprovidesguidelinesastorequireddocumentstobeused
duringandmaintainedaftertheinvestigation.
Example:Physicalabuse
Investigationmaterials:
Complete electronic incidentform
Haveavailable

Witnessstatement(s)
Residentstatement(s)
Accusedstatement(s)
Photographicevidence(ifavailable)
Facilityinvestigation
Careplan(s)
Residentcognitionevaluation
Employeepersonnelandtrainingrecords
Plantopreventreoccurrence

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Themanualaddressesreportableincidentsas
follows:
Topic
Regulatoryreference
Elements
Guidanceoninvestigationmaterialstogather
andhaveavailabletothesurveyor
Q&ArelatedtoNHscenarios

15

ReportsmustbemadetotheDepartmentofHealth
immediately uponachievingtheREASONABLECAUSE
threshold,revealingthatmisappropriationofproperty,
abuse,mistreatmentorneglectoccurred
Immediateisdefinedasassoonaspossible,notto
exceed24hours
Reasonablecauseisdefinedtomeanthatuponareview
ofthecircumstances,thereissufficientevidencefora
prudentpersontobelievethatphysicalabuse,
mistreatmentorneglecthasoccurred
ReportsmustbemadetotheDOHwhenthereasonable
causethresholdhasbeenachieved,revealingabuse,
mistreatmentorneglect
FacilityistonotifyDOHwhentheyhavereached
reasonablecause,andthenhave5workingdaysto
completetheinvestigation.
16

Abusehasnotbeenruledout(especiallywithinjuriesof
unknownorigin)
Facilityinvestigationisinconclusive
Staffstatementsareofpoorqualitynotsignedordated,no
title,lackpertinentinformation
Careplanwasnotappropriatetoresidentsindividualneeds
(Forexample,thecareplanwasnotchangedtoreflect
residentschangeincondition)

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Concerns Identified During

DOH Investigation

Residenthasahistoryofincidentsbutthecare
planfailstoreflectthoseoccurrences
Incidentsaredocumentedonacareplan
withoutinterventionsoraplantoprevent
recurrence
Staffisunawareofchangestotheplanofcare.
Forexample,theCNAcarddoesnotmatchPOC
Careplanisnotalignedwithresidentsneeds.
Forexample,careplanlistsanapproachof
remindersnottostandbutresidenthas
dementiaandcannotremember
Unrealisticgoalsandinterventionsarecare
planned

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Departmentstaffhasexplicitauthoritytoinspectthefacility,
interviewpatientsorresidents,reviewrelevantrecords,
observecarebeingprovidedandconductnecessary
interviews.LicensedfacilitiesmaynotrequiretheDepartment
tomakeanappointmentandmaynotdelayaninspection
OurfederalinvestigationactivitiesareguidedbytheState
OperationsManual(SOM)andrelatedAppendices
TheSOMspecificallyrecognizesthatthedecisiontopermitor
denyfacilitypersonnelinvolvementduringthesurveyprocess
issolelythatofthesurveyor
TheSOMfurthernotesthatrefusalofaccesscanbeabasis
forterminationfromtheparticipationintheMedicareand
Medicaidprograms

19

Theinvestigationleadsyoutodecidewhetherornotto
reporttheissuetotheDepartmentthroughtheHealth
CommerceSystem,IncidentReportingForm
Iftheinvestigationwasthoroughandindicatesthat
abuse,neglect,mistreatmentormisappropriation
occurred,thenitisareportableincident
Iftheinvestigationwasthoroughandoffersnoevidence
ofabuse,mistreatment,neglectormisappropriation,
youcanbejustifiedinnotreportingittotheHotline,
andcannotbecitedforfailuretoreport
Inaddition,someincidentsarereportableunderany
circumstances,iftherequiredelementsarepresent

20

Thefacilitycanbecitedforfailuretocompleteathorough
investigation(Ftag225)if:
Thesurveyorfindsthattheinvestigationfailedtocometoa
reasonableconclusion
Thefacility failedtoinvestigatetheincident
Thefacility canbecitedforfailuretocompleteathorough
investigation(Ftag225)
Ifitwasdeterminedthatabuse,mistreatmentorneglect,or
misappropriationofpropertyoccurredandnotreportedtoDOH,
thentheycanbecitedforfailuretoreport
AnycrimemustbereportedtolawenforcementundertheElder
JusticeLaw.Section1150BoftheSocialSecurityAct(theAct)as
establishedbysection6103(b)(3)ofthePatientProtectionand
AffordableCareAct(AffordableCareAct),requiresspecific
individualsinlongtermcarefacilitiestoreportareasonable
suspicionofcrimescommittedagainstaresident. Thosereports
mustbesubmittedtoonelawenforcementagencyofjurisdiction
andtheStateSurveyAgency(SA).

21

Toreportadditionalinformationtoanexisting
case:
ContacttheCentralizedComplaintIntakeUnit
directlyat18882014563,or
Emailtheintakehotlineat
NHIntake@health.state.ny.us

22

TheDOHhasdevelopedanelectronicincidentreporting
system,whichwillallownursinghomestoreporttheir
incidentsthroughtheHCS
Thenewformwillreplacetheprevioustelephonehotline
methodforreportingincidents
EffectiveOctober17,2011Facilitieswillberequiredto
reportincidentsviathenewIncidentReportingForm
availableontheHCS
TheDepartmenthasprovidedanIncidentReporting
Manualtoclarifythereportingrequirements,andhelp
ensurethatfacilitiesarereportingincidentsrequired
underStateandFederalstatutesandregulations
Themanualprovidesalistofreportableincidentsthat
shallbereportedviatheHCS
TheDepartmentsrequirementsforreportingincidents
areconsistentwithpastreportingrequirements
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ThisPowerPointpresentationhasbeenpreparedtoassist
providerstocompletethoroughinvestigationandto
preparenursinghomeemployeesabouttheprocessfor
investigatingincidents,andwhatconstitutesareportable
incident.Thispresentationisavailableonlineforfuture
viewing
AQuestionandAnswersessionwillbescheduledwiththe
ProviderAssociations.
TheIncidentReportingForm,PowerPointPresentation,and
IncidentReportingManualwillbepostedontheDOH
websitewithintheDearAdministratorLettersection.

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Reportingmechanism:https://commerce.health.state.ny.us
TheformerIncidentReportingLinephonenumber,1888
2014563,maybeusedincaseofanemergencysuchas
yourInternetorcomputersaredown
Detailedinstructionmanualisavailableatthewebsite

25

Iffacilitystaffhavequestionsonthisprocess,
oronreportableincidents,pleasecontact:
Theintakehotlineat18882014563, or
EmailtheIntakemailboxat
Nhintake@health.state.ny.us,or
ContactMarkBrownell,AssistantDirectorof
theBureauofComplaintsandAnalysisor
JoanneBreden,Supervisor,at5184025447

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27

Todetermineifabuse,mistreatment,neglector
misappropriationoccurred
Toassurecompliancewithstatutesandregulations
Toimprovequalityofcare
Toidentifyflawedpractices/policy
Toidentifyandcorrectvulnerabilities
Toassistwithmanagementofrisk

28

Theinvestigationshouldassistthefacilityindeterminingifthe
concernwasaresultof:
Individual(s)action(staffmemberactedontheirown,outside
ofpolicy)
Facilitypractice(flawedpracticeorpolicy)
Didabuse,mistreatment,neglectormisappropriationof
propertyoccur?
Theinvestigationshouldruleoutorconfirmabuse,
mistreatmentorneglectthroughareviewofsupporting
evidence,includinginterviewsandstatementsthatoffervalid
information,observationsandrecordreview
Theoutcomeisdeterminedbyfacts,basedontheevidence
andnotanopinionwhichissubjective

29

Interview

Observation

RecordReview

30

INTERVIEW:Obtainingstatementfrompartiesdirectlyinvolved
andotherspossessingknowledgeofrelevantinformation.This
mayincludestaff,residentsandthirdparty
OBSERVATION:ofthesurroundingsorscenewheretheincident
isallegedtohaveoccurred.Observationofthegeneralcareand
conditionoftheareaisveryimportant
RECORDREVIEW:reviewofmedicalrecords,careplan,any
relateddocuments

31

Renderaidtoprotect theresidents,removingthemfrom
harm
Protectthescene.preserveanyphysicalevidence
Collectevidence(askwho,what,when,whereandhow)
Determinepresenceofintentbyaggressor
Determineyourwitnesses
Conductinterviews
Documentation(incidentreportingform,medicalrecords,
interviewstatements)
Determineifabuse,neglectormistreatmenthasoccurred
Documentyourconclusions

32

CONSIDERTHEFOLLOWING:
Withallegationsofabusemistreatmentorneglect:tryto
leaveareauntouched,asmuchaspossible
Preserveanyevidence/photographs(photosmustbe
dated,timedandabletocorrectlyidentifythesubject)
Makenoteofresidentconditionandenvironmental
conditions
Staffobservation
Circumstancesjustpriortotheeventordiscovery
Evidenceis:Anythingthatwillhelpreconstructthe
incident,identifypeopleinvolvedand/oridentifythe
responsiblepersons

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Obtainingstatementfrompartiesdirectlyinvolvedand
otherspossessinginformation
Anonaccusatoryprocessinwhichtheinterviewerasks
questionsdesignedtodevelopfactualinformation
Documentationmustbesigned,datedandshould
includetheindividualstitle

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Who,what,where,when,whyandhow?
Maintainalistofthequestionsposedtotheindividualsbeing
interviewed
Obtainstatementfromtheresident(s),iftheyareableto
provideastatementabouttheincident,wheneverpossible

35

Takenotesduringtheinterview
Provideprivacy,minimizedistractions;listencarefullyandbe
patient
Whatdoesstaffsay
Areyouinterviewingthemordotheyfilloutaform
Whatkindofquestionsareyouaskingstaff
Questionsshouldbeopenended,designedtoelicit
descriptionsofobservations,interventions,orreenactments

36

Itfrequentlyisnotenoughtohavestaffwritewhatthey
knowDiscussions,includingthefollowingmaybemore
informative.

Describeinteractionwithresident
Physicaldemonstrationofcaredelivered
Didyouseeanyonephysicallyharmresident
Describeforceused,stanceofaccusedandanyinjury
Didyoucheckthechairalarm
Wasitworking
DidyouseeSallyusethegaitbelt
Whatcantheresidentdoindependently
Whatdidthecareplanrequire

37

Writtenstatementsareusuallyneededfromtheaccused,
andfromwitnesses.
Additionalstaffstatementsmaybenecessarytodetermine
whatcarewasdelivered.Wasthecareprovidedin
accordancewiththeindividualizedplanofcare.
Writtenstatementswillneedtobeobtainedinadditionto
theinterviews.

38

Writtenstatementsshouldbe:
Legible
Signed,dated,andindicateshiftandjobtitle
Thepreferenceistohaveindividualwritetheirown
statement,butiftheyareunable,thewritershouldobtain
signatureofindividualorhaveitwitnessed

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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
Hasthestaffmemberbeencounseledforcareissuesor
failuretofollowthecareplaninthepast
Wascareappropriatelydocumented
Doesthisindicatethatthecareplanwasfollowed
Hasthestaffmemberbeeneducatedortrainedinthearea
beinginvestigated,andnotedinthepersonnelrecords

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Allevidenceusedtodeterminetheoutcomeofthe
investigationshouldberelevanttothecase
Ifthecaseisrelatedtoamedicationisahardcopyofthe
properMedicationAdministrationRecordinthecasefile
Ifthecaseisrelatedtoacareplanviolation,isthecareplan
inthecasefile
Allmaterialsrelevanttotheoutcomeshouldbeincludedin
thefile

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Whatisathoroughinvestigation

Onethatcomestoareasonableconclusionastohowand/or
whysomethingoccurred
Theinvestigationshouldruleoutorconfirmabuse,
mistreatmentorneglectbyreviewofsupportingevidence,
includinginterviewsandstatementsthatoffervalid
information,observationsandrecordreview
Theoutcomeisdeterminedbyfact,basedontheevidence
andnotonopinion

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Uponreviewingalloftheevidence,aconclusionisdetermined.

Didabuse,mistreatmentorneglectoccur
Isthereapolicyorpracticeissuethatcausedrisk
Isthisanisolatedincidentorasystemicproblem
Doestheevidencesupporttheoutcome

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Immediately,takecorrectiveactionincludingeducation
Identifytrends
ImplementandcommunicateQIinterventionsforlong
termpreventionofrecurrenceofthematter
Periodicallyreviewandreviseinterventions

Reporttoappropriateagencyasnecessary:

Ifabuse,mistreatment,neglectormisappropriation,
contactlawenforcement
Ifaprofessionalissue,contactStateEducationorDOH
OfficeofProfessionalMisconduct(OPMC)
Ifcontrolledsubstanceissue,contacttheDOHBureauof
NarcoticEnforcement(BNE)
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