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3.07.1 – Peer to Peer Abuse

Reference:      Medicaid Tabs W 148-W157

Licensure Standards  11 5123:2-17-02 E6, E9, G3, and H1

Peer to Peer Abuse is defined in the MUI rule as peer to peer acts.   This means acts committed by one individual against another when an individual is targeting or firmly fixed on another individual such that the act is not accidental or random and the act result in an injury that is treated by a physician, physician assistant, or nurse practitioner.  Allegations of one individual choking another or any head or neck injuries such as a bloody nose, a bloody lip, a black eye, or other injury to the eye, shall be considered major unusual incidents.  Minor injuries such as scratches or reddened areas not involving the head or neck shall be considered unusual incidents an shall require immediate action, a review to uncover possible cause/contributing factors, and prevention measures.

Peer to Peer acts will be reported through the Accident /Incident Report with a phone call to the Incident Hotline Immediately.  The Incident Hotline staff will perform an assessment which will include the intent to harm, functioning level of the aggressor, whether the aggressor was firmly fixed on the individual, and if injury, the location and seriousness of the injury.  The incident will be reported to the county MUI unit within 4 hours of discovery of the incident, if it meets the criteria of a MUI.

The Incident Hotline personnel must immediately put measures in place to ensure the health and welfare of the individual.  This should include removing the aggressor from the area, contacting scheduling if additional staff are needed, or any other measures needed to ensure the health and welfare of the individual.

The Incident Hotline staff will notify the Executive Director, Risk Management Director, and the County Major Unusual Incident Department of the incident.  The Incident Hotline will report MUIs to the MUI Department verbally within 4 hours of discovery of the incident.  The Risk Management department will be responsible for sending the Accident/Incident Report by 3pm the following business day by email.

The Risk Management department will begin the ICF investigation immediately by:

  1. Obtaining statements from all individuals involved.
  2. Obtaining statements from all staff present.
  3. Review necessary documents such as the Person-Centered Plan, IST, Behavior Support Plans, nursing notes, medical paperwork, assessments, and anything else pertinent to the investigation.
  4. Determine the cause and contributing factors for the incident
  5. All results of the internal investigation will be shared with the MUI Investigator within 5 working days. Resources to be used in investigation include:
    1. All copies of incident reports regarding the incident.
    2. Medical observation notes and pictures will be obtained where appropriate.
    3. Behavior Support Plans, and data collection sheets or other pertinent apartment documentation.
  6. A Meeting will be held of the internal investigations.  Preventative Measures will be established to prevent further incidents. The QIDP will be responsible for implementing the prevention plan.  The Residential Services Coordinator will monitor for further revisions as well as the effectiveness of the plan. 

Reporting Responsibilities

Columbus Center for Human Services staff are required to report alleged, suspected, or actual occurrences of abuse or neglect as well as alleged, suspected or actual Major Unusual Incidents to the Incident Hotline on-call personnel IMMEDIATELY. Failure to do so will result in a corrective action. The on-call staff will notify the Chief Executive Director. 

  1. Staff should immediately contact the Incident Hotline to inform them of the allegation or incident.
  2. In the event of an allegation of peer to peer physical aggression, the nurse must be called to make an assessment and to determine whether additional examination is required.
  3. The Incident Hotline or Risk Management Designee shall notify the MUI unit or on call answering service after office hours.
  4. The Incident Hotline or Risk Management Designee will contact the legal guardian or advocate of individuals involved in an peer to peer act immediately of the incident.
Report Contents

Reports should be made immediately by telephone or in person to the appropriate authority with a follow-up written report and shall include the following information:

  • The full names of the individual and person and persons involved in the incident and all potential witnesses of the incident or allegation.
  • Initiation of appropriate internal and FCBDD investigation.
  • Copies of Open Door internal accident/incident reports must be submitted to MUI when such reports involve any situation described in this section by 3pm next business day.
Employee Responsibility

Each employee of Open Door shall be responsible for the following:

  1. Safeguarding individuals from unusual incidents which could be self-inflicted or caused by other individuals, employees, or other persons.
  2.  Reporting unusual incidents (A&I) and calling the Incident Hotline immediately.
Internal Reporting Procedures
  • All allegation of peer to peer acts should be reported to the Chief Executive Director immediately.
  • All allegations of peer to peer acts for the ICF must be investigated by the Risk Management Department  independently or with conjunction of the MUI Department.  The Risk Management Department is the liaison between ICF and the  MUI Dept.
  • All allegations of peer to peer acts for the waiver must be investigated by the MUI Department.  The Risk Management Department is the liaison between waiver and MUI dept.
  • All individuals involved in the reporting of peer to peer acts and/or potential witnesses of a peer to peer acts will be interviewed.  Cooperation from all staff is required in MUI investigations. This includes writing a detailed legible statement.  Anyone who refuses to cooperate is subject to corrective action. 

Evaluation Review/Procedure

All peer to peer acts will be reviewed by the All Incidents will also be reviewed by the designated Monthly UI meetings on a monthly basis.   Review will consist of patterns/trends and preventative measures.   

MUIs, including peer to peer acts will be reviewed at the Executive Staff Meetings monthly.

The MUI Unit will request MUI quarterly reviews throughout the year that includes any peer to peer acts.   This request is generally distributed via memo/email. The Risk Management Department will submit the MUI log when requested in the timeframe given by the MUI unit.  This report will include any peer to peer acts, patterns/trends, and preventative measures for the quarter they have requested.

Last Revised: 2/23/24

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