Incident Reporting

Incident Reporting

(formerly Abuse and Neglect Policy)

POLICY

It is the policy of Mid-Ohio Psychological Services, Inc to maintain records, review data and attempt to alter incidents which pose a risk to the health, safety, and welfare of agency staff, clients, and other persons that interact with this agency.  All incidents that pose a risk to the health, safety, and welfare of agency staff, clients and other persons that interact with this agency will be reported to the Executive and Operations Director.  The Operations Director is responsible for managing the incident appropriately and ensuring that the incident is adequately documented and reported to the appropriate agencies.

It is the responsibility of the Executive Director to assure that the staff is familiarized and comply with this policy and each staff member will be provided a copy of this policy.

 

PROCEDURE

Child Abuse and Neglect Reporting

 

Any staff who is acting in an official or professional capacity and knows, or has reasonable cause to suspect based on facts that would cause a reasonable person in a similar position to suspect, that a child under eighteen years of age, has suffered or faces a threat of suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably indicates abuse or neglect of the child shall immediately report that knowledge. The person making the report shall make it to the public children services agency or a municipal or county peace officer in the county in which the child resides or in which the abuse or neglect is occurring or has occurred.

Client confidentiality, in these cases, is not applicable when reporting abuse or neglect under the parameters outlined above, and reported information is limited to the information reported on the Allegations of Child Abuse Form.  Client information regarding treatment and treatment-related issues not related to the reported incident is protected from unauthorized release and cannot be released without a valid release of information.

The report may be given by telephone and shall be followed by a written report utilizing the Allegations of Child Abuse Form.  The report will include the names and addresses of the child and parents or the person or persons having custody/guardianship of the child, the age of the child, the name and address of the purported offender if available, nature of the abuse or neglect including type, extent, duration, and approximate date(s) of the incident(s), circumstances regarding the abuse or neglect, including any evidence of previous injuries, abuse, or neglect, the child’s current condition, and other information that might be helpful in establishing the cause of the known or suspected injury, abuse, or neglect or the known or suspected threat of injury, abuse, or neglect.

 

 

Failure to report child abuse or neglect may result in a number of punitive actions including termination of employment and professional/criminal sanctions.  The following procedure is to be followed for reporting:

If the client meets the parameters outlined above:

  1. Contact the appropriate agency in the county where the client is a resident or where the abuse occurred providing only the information contained on the Allegations of Child Abuse/Neglect Form.  It is generally advisable to consult with any available clinical supervisor at the clinicians site or another site prior to making a report; however, the staff who is aware of the allegation is responsible for reporting immediately regardless of the consultation.
  2. Complete the Allegations of Child Abuse/Neglect Form and have the form signed by a clinical supervisor if applicable.
  3. Scan the Allegations of Child Abuse/Neglect Form to QA and email the Operations Director.  The original form is placed in the client’s record if a client is party to the allegation or forwarded to the Operations Director if no client is party to the allegation.
  4. A non-billable case note should be created to document that the appropriate reporting occurred or the reporting can be documented in the case note for the service that was provided when the abuse was discovered when a client is party to the allegation.

Staff designated by the Operations Director will then send the completed form to the sheriff or police department in jurisdiction of client residence and OMHAS, if appropriate. Written report will include a space and request for response from the agency to whom reported within 30 days of the date of report.

The ORC applicable to reporting Child Abuse and Neglect can be located at the following link http://codes.ohio.gov/orc/2151.421

Developmentally Disabled Abuse and Neglect Reporting

Any staff who is acting in an official or professional capacity and knows, or has reasonable cause to suspect based on facts that would cause a reasonable person in a similar position to suspect, that a person, under twenty-one years of age with a developmental disability or physical impairment, has suffered or faces a threat of suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably indicates abuse or neglect shall immediately report that knowledge. The person making the report shall make it to the public services agency (Child Protective Services) or a municipal or county peace officer in the county in which the person resides or in which the abuse or neglect is occurring or has occurred.

 

Any staff who is acting in an official or professional capacity and knows, or has reasonable cause to suspect based on facts that would cause a reasonable person in a similar position to suspect, that an adult with a developmental disability who is engaged with a local Board of Developmental Disabilities or would likely be involved with a Board of Developmental Disabilities, has suffered or faces a threat of suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably indicates abuse or neglect shall immediately report that knowledge. The person making the report shall make it to the local Board of Developmental Disabilities or a municipal or county peace officer in the county in which the person resides or in which the abuse or neglect is occurring or has occurred.

 

Client confidentiality, in these cases, is not applicable when reporting abuse or neglect under the parameters outlined above, and reported information is limited to the information reported on the Allegations of DD Abuse Form.  Client information regarding treatment and treatment-related issues not related to the reported incident is protected from unauthorized release and cannot be released without a valid release of information.

The report may be given by telephone and shall be followed by a written report utilizing the Allegations of DD Abuse Form.  The report will include the names and addresses of the person and persons having custody/guardianship of the person, the age of the person, the name and address of the purported offender if available, nature of the abuse or neglect including type, extent, duration, and approximate date(s) of the incident(s), circumstances regarding the abuse or neglect, including any evidence of previous injuries, abuse, or neglect, the person’s current condition, and other information that might be helpful in establishing the cause of the known or suspected injury, abuse, or neglect or the known or suspected threat of injury, abuse, or neglect.

Failure to report DD abuse or neglect may result in a number of punitive actions including termination of employment and professional/criminal sanctions.  The following procedure is to be followed for reporting:

If the client meets the parameters outlined above:

  1. Contact the appropriate agency in the county where the client is a resident or where the abuse occurred providing only the information contained on the Allegations of DD Abuse Form.  For persons under 21 years of age, the report goes to the local Child Protective Services agency and for persons 21 years of age and older, the report goes to the local DD board.   It is generally advisable to consult with any available clinical supervisor at the clinicians site or another site prior to making a report; however, the staff who is aware of the allegation is responsible for reporting immediately regardless of the consultation.
  2. Complete the Allegations of DD Abuse Form and have the form signed by a clinical supervisor if applicable.
  3. Scan the Allegations of DD Abuse Form to QA and email the Operations Director.  The original form is placed in the client’s record if a client is party to the allegation or forwarded to the Operations Director if no client is party to the allegation.
  4. A non-billable case note should be created to document that the appropriate reporting occurred or the reporting can be documented in the case note for the service that was provided when the abuse was discovered when a client is party to the allegation.

Staff designated by the Operations Director will then send the completed form to the sheriff or police department in jurisdiction of client residence and OMHAS, if appropriate. Written report will include a space and request for response from the agency to whom reported within 30 days of the date of report.

The ORC application to reporting Abuse and Neglect for a DD client can be located at the following link http://codes.ohio.gov/orc/5123.61v1

Form:

Allegations of DD Abuse Form

Adult Abuse, Neglect and Exploitation Reporting

Any staff who is acting in an official or professional capacity having reasonable cause to believe that an adult 60 or older is being abused, neglected, or exploited, or is in a condition which is the result of abuse, neglect, or exploitation shall immediately report such belief to the county department of job and family services, Adult Protective Service department.

Client confidentiality, in these cases, is not applicable when reporting abuse, neglect, and exploitation under the parameters outlined above and reported information is limited to the information reported on the Allegations of Adult Abuse Form; however, client information regarding treatment and treatment-related issues not related to the reported incident is protected from unauthorized release.

The report may be given by telephone, and shall be followed by a written report utilizing the Allegations of Adult Abuse Form.  The report will include the names and addresses of the alleged victim, the person or persons with guardianship of the alleged victim, the age of the alleged victim, the name and address of the purported offender if available, nature of the abuse, neglect or exploitation including type, extent, duration, and approximate date(s) of the incident(s), circumstances regarding the abuse or neglect, including any evidence of previous injuries, abuse, or neglect, the alleged victims current condition, and other information that might be helpful in establishing the cause of the known or suspected injury, abuse, neglect or exploitation or the known or suspected threat of injury, abuse, or neglect.

 

Failure to report adult abuse, neglect or exploitation may result in a number of punitive actions including termination of employment and professional sanctions.  The following procedure is to be followed for reporting:

If the client meets the parameters outlined above:

  1. Contact the appropriate agency in the county where the client is a resident or where the abuse occurred providing only the information contained on the Allegations of Adult Abuse Form.  It is generally advisable to consult with any available clinical supervisor at the clinicians site or another site prior to making a report; however, the staff who is aware of the allegation is responsible for reporting immediately regardless of the consultation.
  2. Complete the Allegations of Adult Abuse/Neglect/Exploitation Form and have the form signed by a supervisor if applicable.
  3. Scan the Allegations of Adult Abuse/Neglect/Exploitation Form to QA and email the Operations Director.  The original form is placed in the client’s record.
  4. A non-billable case note should be created to document that the appropriate reporting occurred or the reporting can be documented in the case note for the service that was provided when the abuse was discovered.

Staff designated by the Operations Director will then send the completed form to the sheriff or police department in jurisdiction of client residence and OMHAS, if appropriate. Written report will include a space and request for response from the agency to whom reported within 30 days of the date of report

The ORC applicable to reporting Adult Abuse, Neglect and Exploitation can be located at the following link http://codes.ohio.gov/orc/5101.61v1

Form:

Allegations of Adult Abuse/Neglect/Exploitation Form

 

Abuse Perpetrated by Staff Reporting

Any personnel witnessing or having knowledge of a suspected abuse or neglect incident by other staff persons shall report such information to their supervisor and the Operations Director immediately in writing utilizing the Ohio Department of Mental Health and Addiction Services Community Mental Health/Alcohol and Other Drug Provider Notification of Incident Form, MUI Narrative Form and the Allegations of Child Abuse or Allegations of Adult Abuse Form.  The Operations Director will forward the completed forms to the Mental Health Services Board for the county in which the client resides and OMHAS within 1 working day.  Immediate steps must be taken by the agency to assure the personal safety and well-being of the client.  This includes, but is not limited to, acquiring different residential placements for clients in foster home or other supervised housing situations, re-assignment of clinician, etc.

In the event that the client meets the criteria outlined in the Child Abuse and Neglect or Adult Protective Services sections above, reports should be made immediately as outlined in these sections also.

In dealing administratively with this class of case, charges may be sustained against the employee if the offense is reasonably established on the evidence.  It is not necessary that a finding of abuse be based on proof of guilt beyond a reasonable doubt, as prevails in court determinants.  The trust resting in Mid-Ohio Psychological Services, Inc. for the care of clients is such that charges of abuse must be sustained if the fact of such abuse is reasonably shown by the evidence as a whole pertaining to the case.   Employees, contract staff, student interns and volunteers who are found to neglect or abuse clients will be reported to the appropriate professional regulatory boards and law enforcement authorities where applicable and be terminated from employment.

Forms:

Duty to Protect

Any clinician to whom an explicit threat of serious physical harm to another person or persons or identifiable structure is made, or who is made aware by a knowledgeable person of an explicit threat made by a client, will initiate the duty to protect process. The duty to protect is the responsibility of a clinician to protect clients and others from foreseeable harm. If a client or client’s support person makes statements that suggest a client will engage in harm to others or a specific piece of property, the clinician has the responsibility to take steps to warn intended victims, notify relevant law enforcement, establish a documented safety plan, and/or if necessary, initiate voluntary/involuntary hospitalization consistent with ORC 2305.51 and as outlined in the Duty to Protect form below.

Any explicit threat by a client shall be promptly communicated by the clinician who heard the threat or was made aware of the threat, to any available supervisor. The clinician and supervisor shall determine, based on the client’s history and current condition, whether the threat represents a credible danger to others.

If the clinician/supervisor does not consider the threat to be a credible danger to others, this decision and the reason for this determination shall be documented in the client record.

If the clinician/supervisor considers the threat to be a credible danger, the threat shall be reported promptly to law enforcement where the potential victim resides and/or the location of the alleged aggressor.  The reason for this determination shall be documented in the client record.

Form:

Major Unusual Incidents (MUI)

Major Unusual Events are to be reported immediately.  If the MUI subject is outlined in another area of these procedures, please follow the instructions detailed in those sections as well as the instructions detailed here to make sure all reporting requirements are followed. Major Unusual Incidents include but are not limited to:

  • Death/serious injury of client, employee, contract staff member, volunteer, or student intern, performing tasks for the program or participating in program activities
  • Any allegations of physical/sexual/verbal abuse of a client perpetrated by staff, or any allegations of staff neglect of a client
  • Medication Errors
  • Use of Seclusion/Restraint
  • Outbreak of Class A Serious Communicable Diseases
  • Infection Control
  • Aggression or Violence
  • Use and unauthorized possession of weapons
  • Wandering
  • Elopement
  • Vehicular Accidents
  • Biohazardous Accidents
  • Unauthorized use and possession of legal or illegal substances
  • Suicide, Attempted Suicide, or Death of a Client Under Any Circumstance
  • Sexual Assault
  • Other Sentinel Events

Reportable incidents will be classified into one of three levels by the Executive Director or their designee.

Level One— Death/serious injury of client, employee, contract staff member, volunteer, or student intern, on program premises performing tasks for the program or participating in program activities, any allegations of physical/sexual/verbal abuse of a client, or any allegations of staff neglect of a client.  These events must occur on agency premises or directly involve a staff member of the agency.  All Level One MUI’s should include involvement by law enforcement personnel and/or emergency personnel.  Level One MUI’s will be immediately reported to the ADAMH Board of Residence, the Fairfield County ADAMH Board or board where the event took place, and OMHAS.

Level Two–Level One MUI’s that do not occur on agency premises and do not directly involve agency staff but do affect client care.  Level Two MUI’s typically involve law enforcement personnel and/or emergency personnel.  Level Two MUI’s must be reported to the Fairfield County ADAMH Board and the ADAMH Board of Residence.

Level Three–Level Two MUI’s that do not involve law enforcement personnel and/or emergency personnel but present an opportunity for education or to prevent an event from happening again.

If you are questioning whether a situation is an MUI, report it, and a determination will be made by the Executive Director and the Operations Director.

Guidelines for Completing Forms

The Ohio Department of Mental Health and Addiction Services Community Mental Health/Alcohol and Other Drug Provider Notification of Incident Form DMHAS-0484 or its sequel should always be completed with any MUI.  The MUI Narrative Form is to be used to provide additional space for detail, due to the limited space on the state form.

All forms are to be completed entirely, reviewed and signed by an available supervisor; this can be accomplished in person at your site or by scanning to an available supervisor at another location.  Once the forms are signed they are sent to be scanned to QA and an email is to be sent to the Operations Director and Executive Director.  The original forms are filed in the chart if the incident is related to a client.

All Major Unusual Incidents will be reviewed monthly by the QA Committee with specific attention to patterns and trends being reported to the Executive Director, Operations Director and the Board of Directors.

Forms:

 

Communicable Disease Reporting Instructions
If you become aware of someone with one of the reportable communicable diseases listed here:  List of Disease you are required to report it.
Different classifications have different timelines as to when you must report by.

  • Class A disease – immediately by phone
  • Class B disease – by the end of the next business day
  • Class C disease – by the end of the next business day

Complete the Ohio Reportable Disease Form.  Please refer to the Infectious Disease Control Manual for proper procedure for notifying your local health department.  Class A reporting also requires the Ohio Department of Mental Health and Addiction Services Community Mental Health/Alcohol and Other Drug Provider Notification of Incident Form DMHAS-0484.  After you have reported to the Health Department, Scan the form to QA records and the original goes in the client record.

Form:

Rev.  8/24/2018