MAHSA Annual ConventionMAHSA Annual Convention

May 2, 2007May 2, 2007

Bureau of Health SystemsBureau of Health Systems

UpdateUpdate

Michael Pemble, DirectorMichael Pemble, Director

Division of OperationsDivision of Operations

Bureau of Health SystemsBureau of Health Systems

Question:Question:

Why do the surveyors not stay in the Why do the surveyors not stay in the building until an IJ is removed or building until an IJ is removed or corrected? Subsequently, then how corrected? Subsequently, then how can an IJ be called days after the can an IJ be called days after the surveyor exited the facility? surveyor exited the facility?

Answer:Answer:

Surveyors are not required to stay in the Surveyors are not required to stay in the building until an IJ is removed. building until an IJ is removed.

IJs can be called after exit based on review IJs can be called after exit based on review of information obtained during the survey, of information obtained during the survey, or from other sources after the survey or from other sources after the survey "exit." "exit."

PHC requirement that Division of PHC requirement that Division of Operations Director or Nursing Home Operations Director or Nursing Home Monitoring Director be involved in making Monitoring Director be involved in making IJ decision. See MCL 333.20155(20). IJ decision. See MCL 333.20155(20).

Question:Question:

Why is MPRO the sole agency for Why is MPRO the sole agency for Directed POC’s and Directed In-Directed POC’s and Directed In-services? Could there not be another services? Could there not be another agency or persons available as a agency or persons available as a choice? choice?

Answer:Answer:

MPRO is the service provider of choice for MPRO is the service provider of choice for Directed Inservices and Directed Plans of Directed Inservices and Directed Plans of Correction based on past practice and feedback Correction based on past practice and feedback from BHS managers.from BHS managers.

Problems with availability of MPRO remediators or Problems with availability of MPRO remediators or delays in obtaining service should be brought to delays in obtaining service should be brought to the attention of the manager that required DIT or the attention of the manager that required DIT or DPOC. Special circumstances, e.g. a consultant DPOC. Special circumstances, e.g. a consultant who is already working with a facility and is a who is already working with a facility and is a provider preferred person for remediation can be provider preferred person for remediation can be discussed with BHS manager. discussed with BHS manager.

Question:Question:

If Michigan is awarded the opportunity If Michigan is awarded the opportunity to participate in the QIS survey pilot, to participate in the QIS survey pilot, how would the state implement this? how would the state implement this?

Answer:Answer:

Michigan will not participate in pilot Michigan will not participate in pilot project. CMS has announced that project. CMS has announced that Minnesota will be the only State added Minnesota will be the only State added to the pilot, at this time.to the pilot, at this time.

See CMS S&C 07-09 for description of See CMS S&C 07-09 for description of the pilot.the pilot.

Question:Question:

Why doesn’t the state implement the Why doesn’t the state implement the dining assistant program when other dining assistant program when other states have successfully provided this states have successfully provided this added benefit to the residents for added benefit to the residents for years?years?

Answer:Answer:

The State’s position is it will wait on The State’s position is it will wait on legislative action.legislative action.

Question:Question:

Please explain BHS’s authority to Please explain BHS’s authority to overturn MPRO’s IDR results.overturn MPRO’s IDR results.

Answer:Answer:

SOM 7212C(3) NOTE: Informal dispute resolution is a SOM 7212C(3) NOTE: Informal dispute resolution is a process in which State Agency officials make process in which State Agency officials make determinations of noncompliance. States should be determinations of noncompliance. States should be aware that CMS holds them accountable for the aware that CMS holds them accountable for the legitimacy of the process including the accuracy and legitimacy of the process including the accuracy and reliability on conclusions that are drawn with respect reliability on conclusions that are drawn with respect to survey findings. This means that while States may to survey findings. This means that while States may have the option to involve outside persons or entities have the option to involve outside persons or entities they believe to be qualified to participate in this they believe to be qualified to participate in this process, it is the States, not outside individuals or process, it is the States, not outside individuals or entities, that are responsible for informal dispute entities, that are responsible for informal dispute resolution decisions. CMS will look to the States to resolution decisions. CMS will look to the States to assure the viability of these decision-making assure the viability of these decision-making processes, and holds States accountable for them.processes, and holds States accountable for them.

MPRO offers advisory opinion, so BHS does MPRO offers advisory opinion, so BHS does not technically overturn their decision. We not technically overturn their decision. We don't keep statistics how many times we don't keep statistics how many times we have rejected MPRO opinion to delete have rejected MPRO opinion to delete citation. We reject MPRO opinion when we citation. We reject MPRO opinion when we feel that it does not follow regulations or is feel that it does not follow regulations or is inconsistent with facts.inconsistent with facts.

Question:Question:

Why does Michigan report resident to resident Why does Michigan report resident to resident allegations when the other states within CMS allegations when the other states within CMS Region V report only those with serious injury, those Region V report only those with serious injury, those requiring medical attention or repeat offenders who requiring medical attention or repeat offenders who harmed a resident previously, etc? Could Michigan harmed a resident previously, etc? Could Michigan follow the other states allegation reporting criteria follow the other states allegation reporting criteria to reduce the number of intakes for the state in to reduce the number of intakes for the state in order to more efficiently deal with the volume, order to more efficiently deal with the volume, timelines of investigations, etc?timelines of investigations, etc?

Answer:Answer:

CMS has made it clear, as recently as 2/6/07 that CMS has made it clear, as recently as 2/6/07 that resident to resident altercations are to be reported resident to resident altercations are to be reported as alleged abuse incidents without any qualification as alleged abuse incidents without any qualification of seriousness of injury. Michigan will follow the of seriousness of injury. Michigan will follow the regulations as we understand them and as CMS regulations as we understand them and as CMS directs.directs.

The Facility Reported Incident Log provides an The Facility Reported Incident Log provides an alternative method of reporting non-harm abuse, alternative method of reporting non-harm abuse, neglect each time on Forms 362 and 363.neglect each time on Forms 362 and 363.

Question:Question:

A facility was already cited for F-324 on an A facility was already cited for F-324 on an annual and gave a completion date of 2-18-annual and gave a completion date of 2-18-07. The facility then had a complaint survey 07. The facility then had a complaint survey obviously prior to the POC date and the obviously prior to the POC date and the complaint team cited the same tag. Why complaint team cited the same tag. Why wouldn’t the “Summary Report” just reflect wouldn’t the “Summary Report” just reflect that the facility is already out for F324 and that the facility is already out for F324 and the POC completion date has not been met the POC completion date has not been met so either report amended with the example so either report amended with the example or just stated that facility is working on POC, or just stated that facility is working on POC, etc. Why get a double tag like double etc. Why get a double tag like double jeopardy? jeopardy?

Answer:Answer:

There are no SOM provisions addressing this There are no SOM provisions addressing this situation. Deficiencies may be cited when found. situation. Deficiencies may be cited when found. There is no double jeopardy. Cites are encouraged There is no double jeopardy. Cites are encouraged when a POC is needed because prior cite is different when a POC is needed because prior cite is different example.example.

In the example, the standard survey covered falls In the example, the standard survey covered falls issue, complaint FRI involved falls and elopement. issue, complaint FRI involved falls and elopement. Falls issue was cited as M346, state tag only; Falls issue was cited as M346, state tag only; elopement cited as F-324 and POC required.elopement cited as F-324 and POC required.

Question:Question:

Why are surveys unannounced?Why are surveys unannounced?

Answer:Answer:

Sec. 20155(1) states “A visit made pursuant to a complaint Sec. 20155(1) states “A visit made pursuant to a complaint shall be unannounced.”shall be unannounced.”

SOM, App. P. “Do not announce SNF/NF surveys to the SOM, App. P. “Do not announce SNF/NF surveys to the facility.”facility.”

SOM 2700. “It is CMS policy to have unannounced surveys for SOM 2700. “It is CMS policy to have unannounced surveys for all providers….” “While the unannounced surveys may result all providers….” “While the unannounced surveys may result in some minor inconveniences, this policy represents changing in some minor inconveniences, this policy represents changing public attitudes and expectations toward compliance public attitudes and expectations toward compliance surveys.”surveys.”

Sec. 20155(9) “The department or a local health department Sec. 20155(9) “The department or a local health department shall conduct investigations or inspections, other than shall conduct investigations or inspections, other than inspections of financial records, of a county medical care inspections of financial records, of a county medical care facility, home for the aged, nursing home, or hospice facility, home for the aged, nursing home, or hospice residence without prior notice to the health facility or agency.”residence without prior notice to the health facility or agency.”

Question:Question:

Once a finding of non-compliance Once a finding of non-compliance opens an enforcement cycle, how opens an enforcement cycle, how does that cycle end?does that cycle end?

Answer:Answer:

Compliance Date DeterminationCompliance Date Determination

Compliance can be certified when:Compliance can be certified when:

• AllAll deficiencies have been corrected, or deficiencies have been corrected, or• The facility is in substantial compliance; andThe facility is in substantial compliance; and• The facility provides acceptable evidence to establish The facility provides acceptable evidence to establish

correction.correction.

If the facility is in substantial compliance on the date of the If the facility is in substantial compliance on the date of the first revisit, the compliance date is automatically the date first revisit, the compliance date is automatically the date accepted in the PoC, unless there is evidence that compliance accepted in the PoC, unless there is evidence that compliance was achieved on either an earlier or later date.was achieved on either an earlier or later date.

If the facility is in substantial compliance on the second revisit, If the facility is in substantial compliance on the second revisit, the compliance date is the date observation, record review or the compliance date is the date observation, record review or other evidence substantiates compliance.other evidence substantiates compliance.

Compliance (when correction is verified) is certified as the Compliance (when correction is verified) is certified as the date of the 3date of the 3rdrd or 4 or 4thth revisit. CMS does not allow a compliance revisit. CMS does not allow a compliance date earlier than the revisit date for the third or subsequent date earlier than the revisit date for the third or subsequent revisits.revisits.

When more than one deficiency is involved, the date the When more than one deficiency is involved, the date the facility is considered to be in compliance is the latest of the facility is considered to be in compliance is the latest of the correction dates for the deficiencies. correction dates for the deficiencies.

It should be noted that for OBRA enforcement purposes, It should be noted that for OBRA enforcement purposes, remedies cease when the facility is either in compliance or in remedies cease when the facility is either in compliance or in substantial compliance. If deficiencies are not corrected, but substantial compliance. If deficiencies are not corrected, but yet reduced to substantial compliance level, the substantial yet reduced to substantial compliance level, the substantial compliance date(s) for each deficiency and for the facility compliance date(s) for each deficiency and for the facility overall are evaluated in the same manner as described above.overall are evaluated in the same manner as described above.

Enforcement remedies remain in effect until all deficiencies Enforcement remedies remain in effect until all deficiencies are corrected or the facility achieves substantial compliance.are corrected or the facility achieves substantial compliance.

Interim PolicyInterim Policy for for

Reporting Alleged Reporting Alleged Abuse, Mistreatment, Abuse, Mistreatment,

Neglect, Neglect, Misappropriation and Misappropriation and Injuries of Unknown Injuries of Unknown

SourceSource

CMS Reporting RequirementsCMS Reporting Requirements

42 CFR 483.13(c)(2)42 CFR 483.13(c)(2)

The facility must ensure that all alleged The facility must ensure that all alleged violations involving mistreatment, neglect, violations involving mistreatment, neglect, or abuse, including injuries of unknown or abuse, including injuries of unknown source, and misappropriation of resident source, and misappropriation of resident property are reported immediately to the property are reported immediately to the administrator of the facility and to other administrator of the facility and to other officials in accordance with State law officials in accordance with State law through established procedures (including through established procedures (including to the State survey and certification to the State survey and certification agency).agency).

42 CFR 483.13(c)(4)42 CFR 483.13(c)(4) The results of all investigations must The results of all investigations must

be reported to the administrator or his be reported to the administrator or his designated representative and to designated representative and to other officials in accordance with State other officials in accordance with State law (including to the State survey and law (including to the State survey and certification agency) within 5 working certification agency) within 5 working days of the incident, and if the alleged days of the incident, and if the alleged violation is verified appropriate violation is verified appropriate corrective action must be taken.corrective action must be taken.

CMS NoticeCMS Notice Centers for Medicare & Medicaid Centers for Medicare & Medicaid

Services issues S&C-05-09 (12/16/04)Services issues S&C-05-09 (12/16/04)Reiterates the reporting of alleged violations Reiterates the reporting of alleged violations

and the results of the investigation by and the results of the investigation by nursing homes to the state survey and nursing homes to the state survey and certification agency as mandated by 42 certification agency as mandated by 42 CFR 483.13(c)(2) and (4).CFR 483.13(c)(2) and (4).

Defines the terms “neglect”, “abuse”, “injury Defines the terms “neglect”, “abuse”, “injury of unknown source” “misappropriation of of unknown source” “misappropriation of resident property”, “immediately” and “in resident property”, “immediately” and “in accordance with State law.”accordance with State law.”

Complaint vs. FRI Intake HistoryComplaint vs. FRI Intake History

948565

1208

395

1081

384

1082

210

1342

801

1780

4462

864*

1837*

0500

10001500200025003000350040004500

Complaints FRIs

*FY 2007 data through March 31, 2007.

Facility Reported Incident Intake Facility Reported Incident Intake HistoryHistory

595 395 384

210

801

4462

1837**

3674*

0

500

1000

1500

2000

2500

3000

3500

4000

4500

*Projected based on current totals.

** FRI totals for FY2007, through March 31, 2007.

Facility Reported Incident Intake HistoryFacility Reported Incident Intake HistoryFY 2007FY 2007 Category 3 – Non-UrgentCategory 3 – Non-Urgent

271

245

208

118 122

140

0

50

100

150

200

250

300

Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07

Facility Participation in Facility Facility Participation in Facility Reported Incident LogReported Incident Log

Participating Participating facilitiesfacilities

Non-Non-participatingparticipating

No ResponseNo Response

Detroit Metro Detroit Metro WestWest

4747 2222 1717

Detroit Metro Detroit Metro EastEast

6262 2121 1111

SouthwestSouthwest 6363 1515 1313

Mid-MichiganMid-Michigan 7373 44 1818

Up-NorthUp-North 4848 2222 00

Total Nursing Total Nursing HomesHomes

293293

(67%)(67%)8484

(19%)(19%)5959

(14%)(14%)

ABUSE, NEGLECT, MISTREATMENT, MISAPPROPRIATIONAND INJURY OF UNKNOWN SOURCE INVESTIGATION GUIDE

START HERE WITH AN►ALLEGATION OR SUSPICION OF ABUSE, NEGLECT,

OR MISAPPROPRIATION OF RESIDENT PROPERTY, OR AN

►INJURY OF SUSPICIOUS ORIGIN (FROM PAGE 2)

1. IMMEDIATELY

Secure resident’s safety Assess the resident, provide medical and/or psychosocial treatment as necessary Examine the resident’s injury and/or psychosocial changes and document the description in the medical

record Remove alleged perpetrator (staff, family, or visitor) from contact with all residents and staff pending

outcome of investigation Take measures to prevent recurrence if alleged perpetrator is a resident Document date and time injury was discovered in the resident’s medical record Notify physician if the injury (physical and/or psychosocial) has the potential to require physician

intervention Notify the resident’s legal representative if there is a significant change in health status Immediately (no later than 24 hours) notify the administrator Administrator or designee notifies BHS, local law enforcement, and/or other state agencies as required Immediately (no later than 24 hours) notify BHS of all allegations by one of the following methods:

1) complete the BHS-OPS-362 online submission form found on the BHS website, 2) fax the BHS-OPS-362 form, or 3) call BHS to report followed by a fax of the completed BHS-OPS-362

Facility Incident Report - 24 Hours (BHS-OPS-362)

2. INVESTIGATE

Document date and time of all notifications per facility policy Interview and/or obtain statement from person reporting allegation or suspicion Interview and/or obtain statement from victim/resident Interview and/or obtain statement from alleged perpetrator Interview and/or obtain statements from potential witnesses as determined by the scope of the

investigation Review the resident’s medical record for relevant information (diagnosis, history, similar injuries, etc.) Review materials and complete investigation (refer to abuse investigation protocol and facility policy)

3. WITHIN FIVE WORKING DAYS OF INDCIDENT

Report the results of investigation to the administrator Report the results of investigation to BHS on the BHS-OPS-363 form and submit by fax with

supporting documentation Initiate corrective measures (if applicable) to prevent recurrence

Facility Investigation Report - 5 Working Days(BHS‑OPS-363)

NOTE TO PROVIDERS USING THE FACILITY LOG:

Incidents and findings that involve harm are reported on the BHS-OPS-362 and BHS-OPS-363 forms and recorded on the facility log.

Incidents and findings that do not involve harm are recorded on the facility log only.

INJURY OF UNKNOWN SOURCE (IUS) DETERMINATION

RESIDENT INJURY

(source to be investigated)

1.Was the injury observed by

any person or explained by the resident?

YES

The source of injury is known AND abuse or neglect is alleged or

suspected; return to #1 on Page 1 of the

Investigation Guide and proceed with

immediate action, investigation and report

of alleged abuse/ neglect finding.

The director of nursing (or designated licensed staff) should determine the scope of investigation based on the nature of the injury and professional judgment with the following, "Is the injury suspicious:

A. Because of the extent or location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma), or

B. Due to the number of injuries observed at one particular point in time or the incidence of injuries over time?"

NO

2.Is there a

suspicion that abuse/neglect

may have occurred?

(Box A or B checked)

Return to # 1 on Page 1 of the

Investigation Guide and proceed with immediate action, investigation and report of alleged abuse/neglect

finding.

Document summary of conclusion of investigation.

Review the resident’s plan of care and revise as necessary to prevent recurrence of injury.

Complete determination within 24 hours of incident; no report to BHS is necessary if answers to questions 1 and 2 are “NO.”

YES

NO

MICHIGAN DEPARTMENT OF COMMUNITY HEALTHMICHIGAN DEPARTMENT OF COMMUNITY HEALTHBUREAU OF HEALTH SYSTEMSBUREAU OF HEALTH SYSTEMS

ABUSE ELEMENTS GUIDELINEABUSE ELEMENTS GUIDELINE

ELEMENTS OF ABUSE INCLUDE:ELEMENTS OF ABUSE INCLUDE:

1.1. A RESIDENT TO RESIDENT, STAFF TO RESIDENT OR VISITOR TO RESIDENT ABUSIVE ACT THAT IS A RESIDENT TO RESIDENT, STAFF TO RESIDENT OR VISITOR TO RESIDENT ABUSIVE ACT THAT IS WILLFUL; ORWILLFUL; OR

2.2. NEGLECT;NEGLECT;3.3. (AND) PHYSICAL HARM, PAIN OR MENTAL ANGUISH(AND) PHYSICAL HARM, PAIN OR MENTAL ANGUISH

A. EXAMPLES OF ABUSIVE ACTS ARE:A. EXAMPLES OF ABUSIVE ACTS ARE:-- HITTING,-- HITTING,-- SLAPPING,-- SLAPPING,-- KICKING,-- KICKING,-- UNREASONABLE CONFINEMENT, INVOLUNTARY SECLUSION,-- UNREASONABLE CONFINEMENT, INVOLUNTARY SECLUSION,-- INTIMIDATION,-- INTIMIDATION,-- DELIBERATE INFLICTION OF PAIN INTENDED AS CORRECTION OR PUNISHMENT,-- DELIBERATE INFLICTION OF PAIN INTENDED AS CORRECTION OR PUNISHMENT,-- PHYSICAL THREATS,-- PHYSICAL THREATS,-- USE OF ORAL, WRITTEN, OR GESTURED LANGUAGE THAT WILLFULLY INCLUDES-- USE OF ORAL, WRITTEN, OR GESTURED LANGUAGE THAT WILLFULLY INCLUDES DISPARAGING OR DEROGATORY TERMS TO RESIDENTS OR THEIR FAMILIES,DISPARAGING OR DEROGATORY TERMS TO RESIDENTS OR THEIR FAMILIES,-- HUMILIATION, HARASSMENT, THREATS OF PUNISHMENT OR DEPRIVATION, -- HUMILIATION, HARASSMENT, THREATS OF PUNISHMENT OR DEPRIVATION, -- SEXUAL ABUSE, SEXUAL HARASSMENT, SEXUAL COERCION, OR SEXUAL ASSAULT,-- SEXUAL ABUSE, SEXUAL HARASSMENT, SEXUAL COERCION, OR SEXUAL ASSAULT, UNWELCOME TOUCHING OF A SEXUAL NATURE, REQUEST FOR SEXUAL FAVOR,UNWELCOME TOUCHING OF A SEXUAL NATURE, REQUEST FOR SEXUAL FAVOR,-- INTENTIONALLY WITHHOLDING FOOD, CARE, MEDICATIONS, ASSISTANCE, -- INTENTIONALLY WITHHOLDING FOOD, CARE, MEDICATIONS, ASSISTANCE, -- FAILURE TO PROVIDE GOODS AND SERVICES NECESSARY TO AVOID HARM,-- FAILURE TO PROVIDE GOODS AND SERVICES NECESSARY TO AVOID HARM, MENTAL ANGUISH, MENTAL ILLNESS,MENTAL ANGUISH, MENTAL ILLNESS,-- SEPARATION OF A RESIDENT FROM OTHER RESIDENTS OR OTHER CONFINEMENT-- SEPARATION OF A RESIDENT FROM OTHER RESIDENTS OR OTHER CONFINEMENT AGAINST THE RESIDENT’S WILL.AGAINST THE RESIDENT’S WILL.

B.B. EXAMPLES OF PHYSICAL HARM, PAIN OR MENTAL ANGUISH ARE:EXAMPLES OF PHYSICAL HARM, PAIN OR MENTAL ANGUISH ARE:

-- CUTS, SKIN TEARS, BRUISING, PUFFINESS, TENDERNESS OF THE -- CUTS, SKIN TEARS, BRUISING, PUFFINESS, TENDERNESS OF THE SKIN/MUSCLE, SKIN/MUSCLE,

---- SPRAINS,SPRAINS,

---- FRACTURES,FRACTURES,

-- -- BROKEN BONES,BROKEN BONES,

---- ALL BURNS,ALL BURNS,

---- ANY INJURY THAT IMPAIRS FUNCTION OF ARM, LEG, HAND,ANY INJURY THAT IMPAIRS FUNCTION OF ARM, LEG, HAND,

---- VISIBLE EMOTIONAL DISTRESS; WITHDRAWAL OR FEARVISIBLE EMOTIONAL DISTRESS; WITHDRAWAL OR FEAR

C.C. “WILLFUL” MEANS DELIBERATE OR INTENTIONAL, NOT ACCIDENTAL.“WILLFUL” MEANS DELIBERATE OR INTENTIONAL, NOT ACCIDENTAL.

D.D. INSTANCES OF ABUSE OF ALL RESIDENTS, EVEN THOSE IN A COMA, CAUSE INSTANCES OF ABUSE OF ALL RESIDENTS, EVEN THOSE IN A COMA, CAUSE PHYSICAL HARM, PAIN OR MENTAL ANGUISH.PHYSICAL HARM, PAIN OR MENTAL ANGUISH.

E.E. USE OF DISPARAGING AND DEROGATORY TERMS CAN BE ABUSE REGARDLESS OF USE OF DISPARAGING AND DEROGATORY TERMS CAN BE ABUSE REGARDLESS OF AGE, ABILITY TO COMPREHEND, OR DISABILITY OF RESIDENT.AGE, ABILITY TO COMPREHEND, OR DISABILITY OF RESIDENT.

RULESRULES

1.1. INCIDENTS ARE REPORTABLE ON BHS-OPS-362 IF THEY INCLUDE ELEMENTS FROM “A” AND “B”, INCIDENTS ARE REPORTABLE ON BHS-OPS-362 IF THEY INCLUDE ELEMENTS FROM “A” AND “B”, I.E., AN ABUSIVE ACT AND HARM. THESE INCIDENTS ARE ALSO REPORTED ON THE FACILITY I.E., AN ABUSIVE ACT AND HARM. THESE INCIDENTS ARE ALSO REPORTED ON THE FACILITY LOG.LOG.

2.2. INCIDENTS THAT INCLUDE ELEMENT “A” BUT NOT “B” ARE RECORDED ONLY ON THE FACILITY INCIDENTS THAT INCLUDE ELEMENT “A” BUT NOT “B” ARE RECORDED ONLY ON THE FACILITY LOG, I.E., THERE IS NO “HARM” TO RESIDENT.LOG, I.E., THERE IS NO “HARM” TO RESIDENT.

3.3. INVESTIGATION RESULTS ON BHS-OP-363 ARE REQUIRED IF A BHS-OPS-362 REPORT IS FILED. INVESTIGATION RESULTS ON BHS-OP-363 ARE REQUIRED IF A BHS-OPS-362 REPORT IS FILED. THE INVESTIGATION RESULTS ARE ALSO SUMMARIZED ON THE FACILITY LOG.THE INVESTIGATION RESULTS ARE ALSO SUMMARIZED ON THE FACILITY LOG.

4.4. INVESTIGATION RESULTS FOR NON-HARM ALLEGATIONS ARE REPORTED ONLY ON THE FACILITY INVESTIGATION RESULTS FOR NON-HARM ALLEGATIONS ARE REPORTED ONLY ON THE FACILITY LOG. LOG.

NOTE:NOTE: TO PROVIDERS TO PROVIDERS NOTNOT PARTICIPATING IN “THE INTERIM SYSTEM OF REPORTING ABUSE, PARTICIPATING IN “THE INTERIM SYSTEM OF REPORTING ABUSE, NEGLECT, MISTREATMENT AND MISAPPROPRIATION OF PROPERTY,” ALL INCIDENTS AND NEGLECT, MISTREATMENT AND MISAPPROPRIATION OF PROPERTY,” ALL INCIDENTS AND FINDINGS CONTINUE TO BE REPORTED ON THE BHS-OPS-362 AND BHS-OPS -363.FINDINGS CONTINUE TO BE REPORTED ON THE BHS-OPS-362 AND BHS-OPS -363.

PAST NON-COMPLIANCEPAST NON-COMPLIANCE

To cite past non-compliance, all three (3) of To cite past non-compliance, all three (3) of the following criteria must apply:the following criteria must apply:

1) The facility must have been out of 1) The facility must have been out of compliance with a regulatory requirement compliance with a regulatory requirement at the time the incident occurred.at the time the incident occurred.

2) The non-compliance must have occurred 2) The non-compliance must have occurred after the exit date of the last standard after the exit date of the last standard survey and before the current survey.survey and before the current survey.

PAST NON-COMPLIANCEPAST NON-COMPLIANCE(CONTINUED)(CONTINUED)

3) There must be specific evidence that the 3) There must be specific evidence that the facility corrected the non-compliance, at facility corrected the non-compliance, at the time of the incident, and is in the time of the incident, and is in substantial compliance at the current substantial compliance at the current survey.survey.

Past compliance evidence must show that Past compliance evidence must show that

the facility identified the (alleged) the facility identified the (alleged) deficiency, developed and implemented deficiency, developed and implemented corrective action following the incident.corrective action following the incident.

BHS Website LinksBHS Website Links

Sample Facility Reported Incident logSample Facility Reported Incident log http://www.michigan.gov/document/mdch/bhs_FRI_log_3-22-07_191638_7.dochttp://www.michigan.gov/document/mdch/bhs_FRI_log_3-22-07_191638_7.doc

Abuse and Neglect Investigation GuideAbuse and Neglect Investigation Guide http://www.michigan.gov/documents/mdch/bhs_Abuse_and_Neglect_Investigation_Guide_191625_7.dochttp://www.michigan.gov/documents/mdch/bhs_Abuse_and_Neglect_Investigation_Guide_191625_7.doc

Abuse Elements GuidelineAbuse Elements Guideline http://www.michigan.gov/documents/mdch/bhs_ABUSE_ELEMENTS_CHECKLIST_191628_7.dochttp://www.michigan.gov/documents/mdch/bhs_ABUSE_ELEMENTS_CHECKLIST_191628_7.doc