Self-Report/Facility Reporting Requirements, Including Adult-at-Risk Reporting Requirements

PDF Version of DQA 07-018  (PDF, 36 KB)

Date:   September 14, 2007 -- DQA Memo 07-018
                                                       Supersedes OQA memo 06-030

To:       Adult Day Cares ADC 05
             Adult Family Homes AFH 11
             Community Based Residential Facilities CBRF 11
             Residential Care Apartment Complexes RCAC 11

From:  Kevin Coughlin, Director
             Bureau of Assisted Living

Via:     Otis Woods, Administrator
             Division of Quality Assurance 

Self-Report/Facility Reporting Requirements, Including Adult-at-Risk Reporting Requirements

PURPOSE

The purpose of this memo is to serve as a reference for Adult Day Cares (ADCs), Adult Family Homes (AFHs), Community-based Residential Facilities (CBRFs), and Residential Care Apartment Complexes (RCACs) regarding the types of incidents that need to be reported to the Division of Quality Assurance (DQA). 

These reports, known as self-reports, are required to be submitted to the Department under Wisconsin Stat. ch. 50, and Wis. Admin. Code chs. HFS 83, 88, and 13, and the reporting requirements for Adults-at-Risk under Wis. Stats. §§ 46.90, and 55.043. Providers may also self-report incidents or situations not required by regulation.

REPORTABLE INCIDENTS BY PROVIDER TYPE

AFH

1.  According to § HFS 88.03(5), licensees of AFHs must report to DQA
     the following incidents within the time specified:

a.  Report within seven (7) days any significant and ongoing
     change in the type or amount of services the licensee
     offers to provide, if the change adversely affects any
     resident who needs the service.

b.  Report within seven (7) days any change in household
     members, excluding paid staff, i.e., any person who is not
     a resident but lives in the AFH.

c.  Report within 48 hours that the licensee or service
     provider has pending, has been charged with, or
     convicted of any crime that is substantially related to
     caring for dependent persons.

d.  Report within seven days any change in the home's
     structure or damages to the home that may present a
     hazard to the residents.

e.  (1) Report within 24 hours, any significant change in a
     resident's status, such as, but not limited to, an accident
     requiring hospitalization, elopement from the home, or a
     reportable death. A death shall be reported if there is
     reasonable cause to believe that the death was due to use
     of a physical restraint or psychotropic medication, was a
     suicide, or was accidental.

               (2) Report within three days any death due to incident or
               accident not due to use of a restraint, psychotropic 
               medications, or suicide.

2.  According to § HFS 88.11, an AFH provider who knows, or has
     reasonable cause to suspect, that a resident has been abused or
     neglected as defined in Wis. Stat. §§ 46.90 or 940.285, shall
     immediately, i.e., without delay, contact the licensing agency.

Self-reports are to be sent to the regional office that serves the facility. Providers will generally not receive confirmation from the Department of receipt of a self-report. Once a self-report is received, the Assisted Living Regional Director, or designee, will review the report and determine what actions, if any, are required by the Department.

CBRF

1.  According to Wis. Stat. § 50.035(5)(b) and § HFS 83.19(2), a 
     CBRF must report to DQA the following incidents within the time
     specified:

a.  Report within 24 hours after the death of a resident, if
     there is reasonable cause to believe the death was
     related to the use of a physical restraint or psychotropic
     medication or was a suicide.

b.  Report to DQA within three working days, when a resident
     dies as a result of an incident or accident not related to the
     use of a physical restraint or psychotropic medication, and
     the death was not a suicide.

2.  According to § HFS 83.19(3), a CBRF must send a report to the
     Department within three (3) working days after any of the following
     incidents occurs:

a.  A fire on the premises of the CBRF.

b.  When the licensee, administrator, employee or a resident
     contract a communicable disease required to be reported
     under Wis. Admin. Code ch. HFS 145.

c.  When a resident's whereabouts is unknown and he or she
     is considered missing, and the resident is considered to
     be in danger. The local law enforcement authority shall be
     notified as soon as this determination is made. The CBRF
     shall notify DQA within three (3) calendar days after
     notification of the law enforcement authority. This
     subdivision does not apply to CBRFs serving clients of a
     governmental corrections agency or persons recovering
     from substance abuse.

d.  At any time the police are called to the CBRF as a result
     of actions or incidents that seriously jeopardize the health,
     safety, or welfare of residents or staff. A description of the
     circumstances that required police intervention shall be
     provided to the DQA. This subdivision does not apply to
    CBRFs serving clients of a governmental corrections
    agency.

e.  When an accident occurs resulting in a serious injury
     requiring inpatient hospitalization of a resident.

f.  When a catastrophe occurs resulting in damage to the
    CBRF.

Self-reports are to be sent to the regional office that serves the facility. Providers will generally not receive confirmation from the Department of receipt of a self-report. Once a self report is received, the Assisted Living Regional Director, or designee, will review the report and determine what actions, if any, are required by the Department.

AFHs, CBRFs, and RCACs

1.  All assisted living providers regulated by the DQA, except Adult 
     Day Care providers, must report incidents of caregiver misconduct 
     as defined under Wis. Admin. Code ch. HFS 13, if the incident 
     meets the reporting requirements.

2.  Providers must conduct a complete and thorough investigation of
     allegations of caregiver misconduct (abuse, neglect, 
     misappropriation of property) and injuries of unknown source. 
     The provider must report an incident, i.e., caregiver misconduct 
     or injuries of unknown source, if both of the following conditions are
     true:

a.  There is a reasonable cause to believe they have
     sufficient evidence, or another regulatory authority could
     obtain the evidence, to show the alleged incident
     occurred; AND

b.  There is reasonable cause to believe that the incident
     meets, or could meet, the definition of abuse, neglect, or
     misappropriation.

3.  If you conclude that you must report the incident, then complete
     the Incident Report of Caregiver Misconduct Form (DDE-2447).
     Submit reports of alleged caregiver misconduct and injuries of
     unknown source within seven (7) calendar days of the incident or 
     the date the entity knew of the incident. Submit the completed
     DDE-2447 Incident Report for allegations involving all staff 
     (including credentialed and non-credentialed) to:

Department of Health and Family Services
Division of Quality Assurance
Office of Caregiver Quality
PO Box 2969
Madison, WI 53701-2969

NOTE:  In the past, providers were required to submit the report either to DQA or to the Department of Regulation and Licensing (DRL). This process has been streamlined to eliminate reporting to two different state agencies. 

All caregiver misconduct reports are now submitted to Office of Caregiver Quality (OCQ) staff, who will forward those reports involving credentialed staff (e,g., MDs, RNs, LPNs, Social Workers, etc.) to DRL for review.

Reference: BQA Memo 04-028
Revised Caregiver Misconduct Reporting Requirements for BQA Entities

ADC, AFHs, CBRFs, and RCACs

1.  Wis. Stat. §§ 46.90(4)(ab)1. and 55.043)(1m)(a), requires any
     employee of any entity to report allegations of abuse, neglect or
     exploitation if the adult-at-risk is seen in the course of the person's
     duties and any one of the following conditions is true:

a.  The adult-at-risk has requested the person to make the
      report. This condition means that any entity employee
      must make a report if they are asked to do so.

b.  There is reasonable cause to believe that the adult-at-risk
      is at imminent risk of serious bodily harm, death, sexual
     assault, or significant property loss and is unable to make
     an informed judgment about whether to report the risk.
     This condition requires a concern about future, serious
     risk; it is not applicable to situations that involve past
     incidents only.

c.  Other adults-at-risk are at risk of serious bodily harm,
     death, sexual assault, or significant property loss inflicted
     by the suspected perpetrator. This condition applies to
     reporting past abuse perpetrated on an adult-at-risk only if
     there is a possibility of harm to others. For example, an
     entity employee must report if he or she is made aware of
     a situation involving a specialized transportation van driver
     who allegedly sexually assaulted a client. Even if the client
     no longer uses the transportation service, other
     adults-at-risk would likely be riding with that van driver in
     the future.)

2.  No reporting is required in these two instances:

a.  If the professional believes that filing the report would not
     be in the best interest of the adult-at-risk, and the
     professional documents the reasons for this belief in the
     suspected victim's case file; or

b.  If a health care provider provides treatment by spiritual
     means through prayer for healing in lieu of medical care in
     accordance with his or her religious tradition, and his or
     her communications with patients are required by his or
     her religious denomination to be held confidential.

If you conclude that you must report an incident involving an adult-at-risk, including an elder adult-at-risk, then do the following:

1.  Complete an Incident Report form (DDE-2447) and attach relevant
      internal investigation documents; and

2.  For allegations involving all perpetrators (family member, friend,
     visitor, resident, stranger, etc.), submit the Incident Report within 
     five days to:

Department of Health and Family Services
Division of Quality Assurance
Office of Caregiver Quality
PO Box 2969
Madison, WI 53701-2969

Reference: OQA Memo 06-028
Adult-at-Risk, including Elder Adult-at-Risk, Reporting Requirements For Entities Regulated by the Office of Quality Assurance

ASSISTED LIVING REGIONAL OFFICES

Northern Region
Assisted Living Regional Director
2187 N STEVENS ST STE C
RHINELANDER WI 54501-8036
Phone: (715) 365-2816
Fax: (715) 365-2815

Northeastern Region
Assisted Living Regional Director
200 N JEFFERSON ST STE 211
GREEN BAY WI 54301-5100
Phone: (920) 448-5338
Fax: (920) 448-5254

Southeastern Region
Assisted Living Regional Director
819 N 6th ST RM 609-B
MILWAUKEE WI 53203-1606
Phone: (414) 227-4565
Fax: (414) 227-3903

Southern Region
Assisted Living Regional Director
PO BOX 7940
MADISON, WI 53707-7940
Phone: (608) 266-7474
Fax: (608) 266-8975

Western Region
Assisted Living Regional Director
610 GIBSON ST STE 1
EAU CLAIRE WI 54701-2626
Phone: (715) 836-4029
Fax: (715) 836-2535

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