MDS Alert

Published on Mon Feb 05, 2018 PDF

Post these specific instructions and timelines for reporting resident abuse, neglect, and exploitation, per CMS.

Know these important timelines for preserving resident rights and remaining compliant with abuse reporting. The information quoted below is from "Frequently Asked Questions Related to Long Term Care Regulations, Survey Process, and Training," published by the Centers for Medicare and Medicaid services on Jan. 12, 2018.

"Which cases of abuse and neglect need to be reported within two hours? Within 24 hours?

"The following must be reported immediately but not later than two hours:

1. Is there an allegation of abuse?

If yes, then the facility must report immediately to the administrator, State Survey Agency, adult protective services and other officials in accordance with State law, but not later than 2 hours.

2. Is there an allegation that a resident has suffered serious bodily injury due to neglect, exploitation, mistreatment, or an injury of unknown source?

If yes, then the facility must report immediately to the administrator, State Survey Agency, adult protective services and other officials in accordance with State law, but not later than two hours.

3. Is there a reasonable suspicion of a crime involving a resident suffering serious bodily injury?

If yes, then covered individuals must report immediately to the State Survey Agency and local law enforcement, but not later than two hours.

"The following must be reported not later than 24 hours:

1. Is there a reasonable suspicion of a crime not involving serious bodily injury?

If yes, then covered individuals must report to the State Survey Agency and local law enforcement, not later than 24 hours.

2. Is there an allegation that doesn't involve serious bodily injury of neglect, misappropriation, exploitation, mistreatment, or injury of unknown source?

If yes, then the facility must report to the administrator, State Survey Agency, adult protective services and other officials in accordance with State law, not later than 24 hours."

New Regulations Prohibit Employment of Disciplined Nurses

Make sure your staff are clear of disciplinary actions on their licenses, as new regulations say that facilities risk noncompliance otherwise, according to the same CMS Frequently Asked Questions document.

"If a nurse that currently works for a facility has a disciplinary action on her license are we expected to terminate their employment based on the new regulation?

"In order to meet the Federal requirement at 42 CFR 483.12(a)(3)(iii), a facility must not employ, or otherwise engage individuals, who have a disciplinary action in effect against his/her professional license as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. If a facility employs a nurse where a probation is in effect on his/her nursing license, as a result of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, then the facility would not be in compliance with Federal requirements. We would encourage you to review the terms of the disciplinary action on the license status to determine this."

Prepare for Surveyor Scrutiny, Too

Surveyors are instructed to review abuse allegations through information available via complaints and facility-reported incidents, and to have a good idea of what to expect at a facility before arriving for the survey.

If your facility has reported any incidents or complaints about resident abuse, prepare for surveyors to interview one resident while on-site. The survey team will either select a resident from the initial pool process or ask the facility for a list of residents who have elicited abuse concerns, says CMS in its Frequently Asked Questions document.