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3.07.2 – Allegation of Verbal or Physical or Sexual Abuse

Reference:         Medicaid Tabs W 148-W157

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

Physical Abuse is defined as the use of physical force that can be reasonably be expected to result in harm.

Verbal Abuse is defined as Purposeful use of words or gestures used to threaten coerce, intimidate, harass, or humiliate.

Sexual Abuse is defined as Unlawful sexual conduct or contact, including prohibited sexual relationship with consent.

Verbal, physical or sexual abuse will be reported through the Accident /Incident Report with a phone call to the Incident Hotline on-call staff immediately.  The on-call staff will do some “discovery” which will include investigating the intent to harm, functioning level of the aggressor, whether the aggressor was firmly fixed on the individual and whether there was injury as a result.

The Incident Hotline on-call staff must immediately put measures in place to ensure the health and welfare of the individual.  This should include removing the Primary Person Involved from the schedule, contacting scheduling if additional staff are needed, or any other measures needed to ensure the health and welfare of the individual.

The Incident Hotline on-call staff will notify the  Chief Executive Director and the  County Major Unusual Incident Department of the incident.  The Incident Hotline on-call staff or the Risk Management Department will report MUIs to the MUI Department verbally.  The Risk Management department will be responsible for sending the Accident/Incident Report by 3pm the following business day by email.

Reporting Responsibilities

Open Door staff are required to report alleged, suspected, or actual occurrences of verbal, physical or sexual abuse as well as neglect or other alleged, suspected or actual Major Unusual Incidents to the Incident Hotline On-call Designee IMMEDIATELY.  Failure to do so will result in a corrective action. The on call staff will notify the Director immediately by phone or email. 

  1. Staff should immediately contact the Incident Hotline personnel to inform them of the allegation or incident.
  2. In the event of an allegation of physical or sexual abuse, 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 verbal, physical or sexual 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
  1. All allegations of verbal, physical or sexual abuse should be reported to the Chief Executive Director immediately.
  2. All allegations of verbal, physical or sexual abuse for the ICF must be investigated by the Risk Management Department independently or with conjunction of the MUI Department.  The Risk Management Department designee is the liaison between ICF and the  MUI Dept.
  3. All allegations of abuse for the waiver must be investigated by the MUI Department.  The Risk Management Director is the liaison between waiver and MUI dept.
  4. All individuals involved in the reporting of abuse and/or potential witnesses of abuse will be interviewed.  Cooperation from all staff is required in investigations.  This includes writing a detailed legible statement.  Anyone who refuses to cooperate is subject to a corrective action.

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 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. Must be signed by Director.
  6. 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. IPP’s, Behavior Support Plans, and data collection sheets or other pertinent apartment documentation.
  7. A review of the incident will be done during programming meetings for 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. 

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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