Failure to Update and Implement Current Abuse Reporting Policies
Penalty
Summary
The facility failed to establish and implement an appropriate abuse policy and procedure, as evidenced by an outdated policy titled 'Reporting Abuse' that did not reflect current reporting guidelines. The policy, last revised in 2014, contained instructions that were inconsistent with the requirements outlined in All Facilities Letter 21-26, which mandates specific time frames and reporting entities for incidents involving abuse, neglect, exploitation, or mistreatment. The policy did not clearly align with the updated federal and state requirements for reporting abuse, particularly regarding the time frames and the parties to whom reports must be made. Interviews with staff revealed a lack of understanding and inconsistent knowledge regarding the correct procedures and time frames for reporting abuse allegations. Unlicensed and licensed staff, as well as the Infection Preventionist, provided varying and sometimes incorrect information about whom to notify and when, with some staff stating reports should only be made to certain agencies or within incorrect time frames. This demonstrated that staff were not adequately trained or informed about the current abuse reporting requirements, which could result in delayed or improper reporting of abuse allegations.