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HCFA’s Abuse and Neglect Detection and Prevention Training

INTRODUCTION TO HCFA Manual

The abuse and neglect of individuals receiving services, America’s most vulnerable citizens, have become all too common today. This issue has been spotlighted recently in the media, which report evidence that the problem has reached alarming levels throughout the country’s service environments. Cases of no-show home care workers, overmedication, chiding and demeaning persons with disabilities, malnutrition, and dehydration pervade the health care system and victimize its beneficiaries. In response to this problem, the Health Care Financing Administration (HCFA) has established standardized definitions of abuse and neglect, identified individuals who are most at risk, specified contributing factors, and developed a national strategic approach to combat alleged abuse and neglect of beneficiaries.

Background

In September of 1996, the Government Accounting Office (GAO) released a report concluding that the level of Federal oversight of institutions for persons with mental retardation should be increased. The report identified the potential for conflict of interest when states are both the operators and inspectors of Intermediate Care Facilities for Persons with Mental Retardation (ICFs/MR). In 1997, during partnership surveys of ICFs/MR, HCFA became alarmed by the number of serious and immediate jeopardy issues that were being cited during surveys. In 1998, there were nearly 70 national media notices exposing cases of abuse and neglect and illicit restraints resulting in the death, torture, and fraudulent behavior of staff toward people with developmental disabilities.

To combat these issues of abuse and neglect, HCFA undertook former President Clinton’s new initiative, "Strategic Approach for Improvements to the Survey and Certification Program for Nursing Homes," and simultaneously established an Abuse and Neglect Prevention Forum. These initiatives were designed in part to raise the awareness of the extent of the abuse and neglect problem affecting the elderly and people with disabilities. The initial focus for preventing abuse and neglect was on congregate settings where individuals depend on staff for services and support. HCFA, however, broadened the effort to include home health agencies and psychiatric hospitals after receiving reports that they also had difficulty tracking, reporting, and investigating alleged abuse and neglect incidents.

The Abuse and Neglect Prevention Forum consisted of representatives from a cross section of Federal, state, provider, and advocacy organizations. The Forum met over a one-year period and subsequently formed workgroups to address a variety of topics, including developing critical components that could be included in any entity’s approach to detecting and preventing abuse and neglect. The group identified Seven Key Components that can potentially reduce, detect, and prevent abuse and neglect. Though these components may be part of an entity’s quality improvement process, they could also potentially be a part of a Patient’s Bill of Rights or State Plan Assurances. The seven components, outlined below, form the basis of this provocative training measure to minimize the emerging of abuse and neglect:

1. PREVENT:

The provider has the capacity to detect and prevent the occurrence of abuse and neglect, and reviews specific incidents for "lessons learned," which form a feedback loop to affect necessary policy changes.

2. SCREEN:

The provider makes the effort to determine the appropriateness of prospective employee’s experience in working with individuals with specific conditions and needs, and seeks to identify and verify any previous charges of abuse and neglect of a prospective employee. The provider also screens individuals receiving services to determine whether the individual’s needs can be appropriately addressed within the provider’s setting.

3. IDENTIFY:

The provider creates and maintains a proactive approach for identifying and occurrences that may constitute or contribute to abuse and neglect.

4. TRAIN:

The provider gives all employees¾ trough orientation and ongoing training program¾ information regarding abuse and neglect. Training should include reporting requirements and procedures for detection, intervention, and prevention. Individuals receiving services should be trained to recognize and identify signs and symptoms of abuse and neglect; they should also be informed of ways in which they and their family members can support detection and prevention efforts.

5. PROTECT:

The provider seeks generally to support and protect individuals receiving services, their families, and staff. Additionally, the provider makes an effort to protect individuals from abuse and neglect during investigation of allegations of abuse or neglect.

6. REPORT AND INVESTIGATE:

The provider puts in place measures that facilitate and assure the reporting of abuse and neglect. The provider also assures a timely, thorough, and objective investigation of all allegations of abuse, neglect, or mistreatment.

7. RESPOND:

The provider assures that the appropriate corrective, remedial, or disciplinary action occurs in accordance with applicable local, state, or Federal law, in response to findings resulting from investigations.

These Seven Key Components comprise an integrated approach for the detection and prevention of abuse and neglect. The objective of this approach is to address abuse and neglect at critical points in program planning, policy development, and operations.

Purpose and Framework for Surveyors/Reviewers

The intent of this training is to provide surveyors/reviewers with suggested guidelines for identifying and assessing a provider’s approach to program assessment, planning, implementation, monitoring, and quality improvement for the detection and prevention of abuse and neglect. While some of the information contained in the following curriculum may be corroborated in regulation, it is not a regulatory guide. The curriculum is designed to be universally applicable to all provider types regardless of the regulatory language used. It is written with a focus on detection and with the understanding that surveyors/reviewers need to know and understand what constitutes an effective, proactive approach to the detection and prevention of abuse and neglect. Therefore, the curriculum is designed to give surveyors/reviewers basic information that can be applied during survey and review processes.

In preparation for participation in the HCFA Abuse and Neglect Detection and Prevention training, it is important that surveyors/reviewers are aware of the framework that will guide their learning experience:

1. The focus of the curriculum is to provide a generic approach to the detection and prevention of abuse and neglect that can be applied across a variety of provider settings. With that in mind, efforts have been made to use universal terminology is most instances so as not to give the impression that any of the practices or procedures discussed in the training are relevant only to a specific provider setting. For example, instead of using the term "client" or "resident," those who receive provider services are simply referred to as "individuals who receive services." It is important that surveyors/reviewers understand that the focus of the training is directed not toward a particular provider setting, but rather on situations and circumstances having common threads that connect issues, concerns, and approaches related to abuse and neglect.
   
2. The emphasis of the content is directed toward identifying the best practices in the approach to establishing and/or implementing policies, processes that allow providers to detect the occurrence, and detect and prevent the reoccurrence, of abuse and neglect. While there is no expectation that providers will have all of the identified practices in place, it is important for surveyors/reviewers to have a baseline from which to make a determination of a provider’s effectiveness in detecting and preventing abuse and neglect.
   
3. The Seven Key Components are to be utilized as a comprehensive, proactive approach to the detection and prevention of abuse and neglect. The emphasis if the training is to explore whether providers have integrated abuse and neglect detection and prevention in their overall organizational operations, such as program assessment, planning, implementation, monitoring, and quality improvement. The training will explore specific incidents of abuse and neglect, but the focus will be directed toward how providers have used lessons learned from those incidents to make needed changes or adjustments to their service delivery system or approach.
   
4. The materials and information provided are intended to supplement the ongoing survey/review process as opposed to creating an additional task. It is assumed that many of the recommended areas of inquiry are currently used by surveyors/reviewers in other focus areas. The aim of the training is to provide surveyors/reviewers with a tool that will allow them to integrate the exploration of providers’ abuse and neglect detection and prevention efforts in all aspects of the survey/review process.

Surveyors/reviewers are encouraged to keep the framework in mind as they participate in the training, and to use the information provided as cues for exploring the effectiveness of providers’ efforts to identify, address, and eliminate the reoccurrence of abuse and neglect.

Training Purpose and Objectives

The HCFA Abuse and Neglect Detection and Prevention curriculum is designed to teach surveyors/reviewers what to look for when assessing a provider’s measures for detecting and preventing abuse and neglect. Overall, the focus of the training is to prepare surveyors/reviewers to:

1. Understand the various forms of abuse and neglect

2. Recognize possible indicators of abuse and neglect

3. Understand the universal principles and practices of an integrated approach to detecting and preventing abuse and neglect

4. Utilize the Seven Key Components to identify and assess a provider’s approach to detecting, responding to, and preventing abuse and neglect

5. Determine if a provider has an integrated approach to program planning, monitoring, and assessment to detect and prevent abuse neglect

HCFA’s Definitions of Abuse and Neglect

It is important for a participant in the survey/review process, to be familiar with HCFA’s approved definitions of abuse and neglect as well as other commonly used definitions. Abuse and neglect exist in many forms and to varying degrees. They may also be defined differently by states, professional service organizations, community law enforcement agencies, and providers. These definitions are to be used consistently for all HCFA provider types.

The Code of Federal Regulations provides the following regulator definitions of abuse and neglect at 42 CFR 488.301:

ABUSE is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.

NEGLECT is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.

Types of Abuse and Neglect Among HCFA Beneficiaries

There are three basic types of abuse associated with the settings in which individuals receive services:

1. Domestic Abuse: Any form of abuse or neglect of an individual receiving services by someone with whom he/she has a personal relationship (i.e., spouse, child, sibling, friend, or caregiver).
   
2. Institutional Abuse: All forms of abuse and neglect of an individual that occur in an institutional setting, specifically a residential facility (i.e., nursing home, personal care boarding home, foster home, group home, intermediate care facility for persons with mental retardation, mental health treatment center, or hospital). Perpetrators of institutional abuse usually are persons who have a legal or contractual obligation to provide care and protection; however, residents can also abuse other residents.
   
3. Self-Abuse or Self-Neglect: Characterized as a behavior of the individual receiving services that threatens his/her own safety (i.e., refusal or failure to provide himself/herself with adequate food, water, clothing, shelter, personal hygiene, medication, or safety precautions). This excludes a situation in which a mentally competent adult¾ who understands the consequences of his/her actions¾ consciously and voluntarily chooses to engage in an act or acts that threaten his/her health and safety.

Other Definitions of Abuse

Although the following list of terms and definitions may differ among provider types, many of these are commonly used in HCFA regulations. Others presented here are those generally used to describe conditions of abuse and neglect. Please note that this information is not intended to be exhaustive, but rather to provide examples of abuse and neglect as they may occur in different situations.

Physical Abuse: The use of physical force that may result in bodily injury, physical pain, or impairment.

• Punishing, slapping, hitting, shoving striking with or without an object, pinching, kicking, burning

• Physical punishment, confinement, or unlawful use of restraints

• Corporal punishment

Sexual Assault: Sexual contact that results from threats, force, or the inability of the person to give consent, and involving a range of activities, including, but not limited to, assault, rape, or sexual harassment.

• Exhibitionism by the service provider
• Forcing the individual receiving services to view pornographic material
• Intimate touching of the individual receiving services by the service provider during bathing
• Molesting the individual receiving services, including sexual touching or kissing
• Any sexual activity that occurs when an individual cannot or does not consent

Misuse of Restraints: Chemical or physical control of the individual receiving services beyond physician’s orders or not in accordance with accepted professional practice.

Chemical restraint: Any drug that is used for discipline or convenience and not considered accepted professional practice to treat medical or behavioral symptoms.

Physical restraint: Any manual method or physical or mechanical device, material, or equipment attached or adjacent to the individual’s body that he/she cannot remove easily and that restricts freedom of movement or normal access to his/her body.

• Staff failing to follow protocol to loosen, reposition, or remove restraints
• Attempting to alter the individual’s behavior with inappropriate use of drugs
• Inappropriate use of side rails, leg restraints, arm restraints, hand mitts, soft ties or vests, lap cushions, lap tray, bars, or belts
• Inappropriately locked rooms, wards, or environmental mechanisms that prohibit the individual’s free movement

Emotional or Psychological Abuse: The verbal or nonverbal infliction of anguish, pain, or distress that results in mental or emotional suffering.

• Demeaning statements, harassment, threats, insults, humiliation, intimidation
• Isolating the individual from friends, family, or normal activities
• Threatening harm or deprivation with verbal or nonverbal threats or gestures
• Failure to offer a choice when the individual is capable of making choices

Physical Neglect: The deprivation of goods and services necessary to maintain physical or mental health.

• Withholding food, fluids, clothing, shelter, personal hygiene, medicine, comfort, safety, help, or other essentials included in implied or contractual agreement of responsibility to an individual receiving services
• Applying a behavior management technique that results in, or has the potential to result in, physical or psychological harm

Medical Neglect: Failure to provide care for existing medical problems.

• Not taking action on medical problems, prescribed treatment, or therapies
• Not calling a physician when necessary, i.e., change of status
• Failure to monitor for adverse drug reactions

Abandonment: The desertion of an individual receiving services by any person who has assumed responsibility for providing care or by a person who has physical custody of that individual.

• Desertion at a hospital, nursing facility, or similar institution
• Desertion at a public location such as a shopping mall or in a vehicle
• An individual’s own report of being abandoned

Financial or Material Exploitation: Illegal or improper use of an individual’s funds, property, or assets without informed consent and resulting in monetary, personal or other benefit, gain, or profit for the perpetrator; or monetary or personal loss by the individual.

• Utilizing position of authority to take advantage of an individual for personal gain
• Stealing, cashing checks without permission, forging signatures, misusing money or possessions
• Improper use of conservatorship, guardianship, or power of attorney

Self-Abuse or self-Neglect: The behavior of an individual that threatens his/her own safety

• Refusal to provide him/herself with adequate food, water, clothing, shelter, personal hygiene.

Signs and Symptoms of Abuse and Neglect

Among health care professionals there has been continuing discussion regarding the clinical indicators that support the suspicion that abuse and neglect may have occurred. Because of the vulnerability of individuals receiving services, there may be a higher incidence of injury and/or death resulting from physical abuse than among less vulnerable individuals.

The following signs and symptoms are examples of possible indicators of abuse:

• Bruises, black eyes, welts, lacerations, rope marks, imprint injuries
• Fractures*
• Open wounds, cuts, punctures
• Sprains or dislocations
• Unexplained venereal disease or genital infections
• Unexplained vaginal or anal bleeding
• Bruises around the breast or genital area

* The occurrence of fractures is not proof of abuse or neglect; however, delayed detection or the mismanagement of fractures or their mismanagement may be. It is important to note that there is still much debate among professionals about whether elderly osteoporotic patients sustain fractures from falls or whether "spontaneous " fractures causes falls. Among elderly individuals, it is common to find underlying malignancies with bone metastasis that may lead to fractures without evidence of a traumatic event.

The following signs and symptoms are examples of possible indicators of neglect:

• Malnutrition or dehydration that is not a result of terminal illness or end-stage disease, where a patient or surrogate has declined intervention

• Contractures that become fixed, even in an individual with certain neurological conditions, due to lack of consultation or active management

• Pressure ulcers without evidence of predisposing medical conditions that may increase risk of pressure sore development or evidence of preventive measures or intervention

The following are examples of psychosocial behaviors that may indicate either abuse or neglect:

• Unexplained restlessness
• Beneficiaries appear inexplicably timid, shy, reticent, or withdrawn
• Beneficiaries are nervous or exhibit aimless wandering without provocation
• Lack of interaction between individuals and staff
• Beneficiaries avoid staff attention and appear fearful, angry, stressed, defensive, anxious, or worried
• Tearfulness, crying
• Unexplained poor personal hygiene

Other Resources for the Protection of Individual Receiving Services

This issue of detection and prevention of abuse and neglect has drawn much attention. Regulations now exist at Federal, state, and local levels that impact on service providers. In addition to regulatory enforcement, law enforcement at every level has assumed a role in the detection and prevention of abuse and neglect. Below are a few of the programs involved in detecting and preventing abuse and neglect. Programs that are not federally regulated may differ according to state and local laws:

• Federal Regulations: Abuse of beneficiaries was the incentive for reinforcing and improving residents’ rights, nurse aide training, and competency evaluation requirements under HCFA regulations.

• Professional Licensing: Many health care professional, including physicians, psychologists, nurses, therapists (physical, occupational, speech), and social workers, hold licenses that compel them to act in accordance with acceptable practice for their profession. Licensing is regulated by individual states and may not always be consistent.
• Nurse Aide Registry: Some HCFA regulations (i.e., Home Health Agencies and Long-Term Care) require that states maintain a registry of all individuals who have successfully completed a state-approved training or competency evaluation program. The registry also contains findings by state survey agencies of abuse, neglect, or misappropriation of individual property by individual nurse aides. Nursing facilities, for example, may not employ anyone with a history of abusing, neglecting, or mistreating individuals. The registry is also available to administrators in other care settings since care staff may change work venues. Although there is not an interstate registry, it may be possible for providers to check registries in neighboring states.

• Protection and Advocacy: The "Protection and Advocacy for Persons with Developmental Disabilities (PADD) Program" was created by the Developmental Disabilities Assistance and Bill of Rights (DD) Act of 1975. It is a federally mandated system operating in each state and territory that provides protection of the rights of persons with disabilities through legally based advocacy. Protection and Advocacy agencies (P&As) were established to address public outcry in response to the abuse, neglect, and lack of programming in institutions for persons with disabilities. Congress has created distinct statutory programs to address the needs of different populations of persons with disabilities. P&As are required by this Act to pursue legal, administrative, or other appropriate remedies to protect and advocate for the rights of individuals with developmental disabilities under all applicable Federal and state laws. The governor of each state designates one agency to be the P&A system and provides assurance that the system is and will remain independent of any service provider.

• State Protective Services and Licensing Laws: All 50 states and Washington, D.C., prohibit the neglect and abuse of children and older individuals, both in private homes and in institutions. Some states require the reporting of suspected abuse or neglect of residents living in institutions licensed by the state. States may also expand the law to apply to all adults, not just to children and elderly.

• Nursing Home Initiative: Developed in 1998 by the U.S. Department of Justice, this initiative focuses on:

1. Increasing investigations and prosecutions of abuse at the Federal, state, and local levels
2. Improving coordination and information sharing between the U.S. Department of Justice and Federal, state, and local agencies
3. Introducing new legislation to address gaps in current Federal and criminal laws
4. Renewing efforts to work with industry to improve compliance
5. Training regulators, investigators, prosecutors, advocates, and other how to and respond to abuse, fraud, and neglect

What Does This Mean for Surveyors/Reviewers?

The criteria by which an entity detects and prevents abuse and neglect may be revealed in the answers to these guiding questions: How does the entity apply the Federal definitions of abuse and neglect? Has the entity’s approach to program assessment, planning, implementation, monitoring, and quality improvement for the detection and prevention of abuse and neglect effectively detected or prevented improvement for the detection and prevention of abuse and neglect effectively detected or prevented abuse and neglect? Through observation and discussion during the survey/review process, the surveyor/reviewer can ascertain whether the entity has in place an approach for preventing and detecting abuse and neglect¾ and whether that approach is understood by the individuals served as well as by the care staff. Familiarity with the signs and symptoms of abuse and neglect will help the surveyor/reviewer determine the effectiveness of the entity’s method for detecting and preventing abuse and neglect.

Using HCFA’s definitions of abuse and neglect as they apply to the entity under review, the surveyor/reviewer should look for signs and symptoms that may indicate evidence of abuse or neglect. The surveyor/reviewer should carefully observe and question individuals who are receiving services and the surveyor/reviewer should also observe individuals’ living and working environments. Additionally, the surveyor/reviewer should question members of the staff. This review process will assist the surveyor/reviewer in identifying the presence of abuse or neglect. This process will also help to ascertain whether beneficiaries and staff understand what abuse and neglect is¾ and whether they are cognizant of the organization’s method or approach for detecting and reporting it. The basic question is this: Can individuals and staff identify abuse and neglect, and do they know what actions or steps to take if abuse or neglect occur?

Through a series of scenarios, discussions, and exercises, we will examine the issues of abuse and neglect and highlight strategies for minimizing occurrences. This will be done within the framework of the Abuse and Neglect Prevention Forum’s Seven Key Components for monitoring, detecting, and preventing abuse and neglect.

Reference*

**1. Sobsey, D. (1994). Violence and abuse in the lives of people with disabilities: The end of silent Acceptance. Baltimore: Paul H. Brookes Publishing Co.

**2. Reno, J. (2000). Elder Justice: Medical/Forensic issues concerning institutional abuse and neglect. Paper submitted for discussion for Elder Justice: Medical/Forensic Issues Concerning Abuse and Neglect. Washington, DC. October.

* Please note that some references may be cited more than once in the reading.

* Denotes references cited in Instructor Notes.

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