Document 6551342

Licking County Board of Developmental Disabilities
Administrative Policy Manual
Policy: Incidents Adversely Affecting
Health & Safety
Board Approved: 4/96
Revised: 2/02, 2/07, 5/14
Reviewed: 06/10
Section: 3.2
Page 1 of 11
POLICY
The Licking County Board of Developmental Disabilities, hereinafter referred to as the Board, is
committed to responding to incidents that adversely affect the health and safety of persons with
developmental disabilities in accordance with OAC 5123:2-17-02, and to use a continuous quality
improvement process to prevent or reduce, to the extent possible, the risk of harm to eligible
persons.
This policy applies to the Board; licensed/certified providers; and to the Mid-East Ohio Regional
Advisory Council, hereinafter referred to as MEORC, the regional council of government to which
the Board belongs. Nothing in this policy relieves any person of the responsibility to comply with
section 5123.61 of the Ohio Revised Code, which requires the reporting of abuse, neglect, and
misappropriation.
The purpose of this policy is to establish requirements for appropriate and timely reporting and
investigation of alleged or suspected major unusual incidents and unusual incidents as defined in
OAC 5123:2-17-02. Additionally, this policy establishes the expectation that clearly defined and
well-communicated procedures will be utilized by the Board and all providers under contract with
the Board to report, respond and follow up on alleged and suspected unusual and major unusual
incidents.
This policy and related procedures require the following:
 Appropriate Preventive actions are taken to ensure individual health and welfare;
 Prompt and accurate reporting of each incident;
 Actions are taken to prevent or reduce the risk of recurrence;
 Appropriate and immediate investigation of all alleged or suspected Major Unusual
Incidents;
 Appropriate follow up regarding all unusual incidents.
Consistent with the terms of the Board's agreement with MEORC, responsibility for taking reports
of suspected/alleged major unusual incidents; filing reports as required by rule; reviewing and
investigating incidents in accordance with ORC 5126.221 and other applicable federal and state
statues; and relevant rules and regulations, lies with MEORC. MEORC employs investigative
agents who perform the duties of investigative agents for the Licking County Board of
Developmental Disabilities. Investigative agents employed by MEORC are certified by the
Department of Developmental Disabilities consistent with rules adopted under ORC 5126.25 and
certification standards defined in OAC 5123:2-5-07.
Licking County Board of Developmental Disabilities
Administrative Policy Manual
Policy: Incidents Adversely Affecting
Health & Safety
Board Approved: 4/96
Revised: 2/02, 2/07, 5/14
Reviewed: 06/10
Section: 3.2
Page 2 of 11
DEFINITIONS
The following terms and definitions that are included in OAC 5123:2-17-02 are included here for
ease in reading and understanding this policy and related procedures.
A. “Abuser Registry” means the registry that was established by Ohio law to prohibit people
from working with people if they have committed acts of abuse, neglect, misappropriation,
failure to report and/or prohibited sexual relations which meet the criteria for placement on
the Ohio Department of Developmental Disabilities Abuser Registry.
B. “Administrative Investigation” means the gathering and analysis of information related to
a major unusual incident so that appropriate action can be taken to address any harm or risk
of harm, and prevent recurrence.
1. There are three administrative investigation procedures that correspond with the three
major unusual incident categories delineated in the definition section of this procedure:
a. Category A – for allegations of accidental or suspicious death, exploitation, failure
to report, misappropriation, neglect, peer-to-peer act, physical abuse, prohibited
sexual relations, rights code violation, sexual abuse, and verbal abuse. Further
information regarding Category A investigation procedures is included in Appendix
A of this procedure;
b. Category B – for allegations of attempted suicide, death other than accidental or
suspicious death, medical emergency, missing person, and significant injury.
Further information regarding Category B investigation procedures is included in
Appendix B of this procedure; and
c. Category C – for allegations of law enforcement involvement, unapproved behavior
support, and unscheduled hospitalization. Further information regarding Category C
investigation procedures is included in Appendix C of this procedure.
C. “At-Risk Person” means a person whose health and/or welfare is adversely affected or
whose health and/or welfare may reasonably be considered to be in danger of being
adversely affected.
D. “Incident Report” means documentation that contains details about a major unusual
incident or an unusual incident, and shall include, but is not limited to:
Licking County Board of Developmental Disabilities
Administrative Policy Manual
Policy: Incidents Adversely Affecting
Health & Safety
Board Approved: 4/96
Revised: 2/02, 2/07, 5/14
Reviewed: 06/10
Section: 3.2
Page 3 of 11
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Person’s name;
Person’s address;
Date of incident;
Time of incident;
Location of incident;
Description of incident;
Type and location of injuries;
Immediate actions taken to ensure health and welfare of person involved and any atrisk persons;
Name(s) of Primary Person(s) Involved (PPI) and his/her relationship to the Person;
Name(s) of witness(es);
Name of agency/independent provider who was providing services at the time of the
incident;
Statement(s) completed by person(s) who witnessed or have personal knowledge of the
incident;
Notifications with name, title, and time and date of notice;
Further medical follow up;
Name, signature, and title of person completing the incident report;
Cause and contributing factors;
Follow up information; and
Prevention Plan.
E. “Incident Tracking System (ITS)” means DODD’s web-based system for reporting major
unusual incidents.
F. “Mid-East Ohio Regional Council (MEORC)” means a regional council of governments
as established under ORC 167 who is under contract to provide services to the county board
and functions as a part of the county board when providing said services.
G. “Major Unusual Incident (MUI)” means the alleged, suspected, or actual occurrence of
an incident when there is reason to believe the health and/or welfare of a person may be
adversely affected, or a person may be placed at a likely risk of harm, if such person is
receiving services through the developmental disabilities services delivery system, or will
be receiving such services as a result of the incident. There are three categories of major
Licking County Board of Developmental Disabilities
Administrative Policy Manual
Policy: Incidents Adversely Affecting
Health & Safety
Board Approved: 4/96
Revised: 2/02, 2/07, 5/14
Reviewed: 06/10
Section: 3.2
Page 4 of 11
unusual incidents (MUIs) that correspond to the three administrative investigation
procedures delineated in Appendix A, Appendix, B, and Appendix C of this procedure:
1.
Category A
a. “Accidental or Suspicious Death” means the death of a person resulting from an
accident or suspicious circumstances;
b. “Exploitation” means the unlawful or improper act of using a person or a person’s
resources for monetary or personal benefit, profit, and/or gain;
c. “Failure to Report” means that a person, who is required to report pursuant to
ORC 5123.61, has reason to believe that a person has suffered or faces a substantial
risk of suffering any wound, injury, disability, or condition of such a nature as to
reasonably indicate abuse, misappropriation, or exploitation that results in a risk to
health and welfare or neglect of that person, and such person does not immediately
report such information to a law enforcement agency, a county board, or, in the case
of a person living in a developmental center, either to law enforcement or DODD.
Pursuant to ORC 5123.61 (C) (1), such report shall be made to DODD and the
county board when the incident involves an act or omission of an employee of a
county board. Further information is contained in Section XIX of this procedure;
d. “Misappropriation” means depriving, defrauding, or otherwise obtaining the real
or personal property of a person by any means prohibited by the ORC, including
ORC Chapters 2911 and 2913;
e. “Neglect” means when there is a duty to do so, failing to provide a person with any
treatment, care, goods, supervision, or services necessary to maintain the health
and/or welfare of the person;
f. “Peer-to–Peer Act” means one of the following incidents involving two persons
served:
“Peer-to-Peer Exploitation” means the unlawful or improper act of using a
person or a person’s resources for monetary or person benefit, profit, or gain;
ii. “Peer-to-Peer Theft” means intentionally depriving another person or real or
personal property valued at twenty dollars ($20) or more, or property of
significant personal value to the person;
iii. “Peer-to-Peer Physical Act” means a person is targeting, or firmly fixed, on
another person such that the act is not accidental or random, and the act results
in an injury that is treated by a physician, physician assistant, or nurse
i.
Licking County Board of Developmental Disabilities
Administrative Policy Manual
Policy: Incidents Adversely Affecting
Health & Safety
Board Approved: 4/96
Revised: 2/02, 2/07, 5/14
Reviewed: 06/10
Section: 3.2
Page 5 of 11
practitioner. Allegations of one person 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 and shall require immediate action, a review to uncover
possible cause/contributing factors, and prevention measures;
iv. “Peer-to-Peer Sexual Act” means sexual conduct and/or contact for the
purposes of sexual gratification without the consent of the other person;
v. “Peer-to-Peer Verbal Act” means the use of words, gestures, or other
communicative methods to purposefully threaten, coerce, or intimidate the other
person when there is the opportunity and ability to carry out the threat.
g. “Physical Abuse” means the use of physical force that can reasonably be expected
to result in physical harm or serious physical harm as those terms are defined in
ORC 2901.01. Such force may include, but is not limited to, hitting, slapping,
pushing, or throwing objects at a person.
h. “Prohibited Sexual Relations” means a developmental disabilities employee
engaging in consensual sexual conduct, or having consensual sexual contact with a
person who is not the employee’s spouse, and for whom the developmental
disabilities employee was employed or under contract to provide care or supervise
the provision of care at the time of the incident.
i. “Rights Code Violation” means any violation of the rights enumerated in ORC
5123.62 that creates a likely risk of harm to the health and/or welfare of a person.
“Sexual Abuse” means unlawful sexual conduct or sexual contact as those terms are
defined in ORC 2907.01 and the commission of any act prohibited by ORC 2907 (e.g.
public indecency, importuning, and voyeurism).
k. “Verbal Abuse” means the use of words, gestures or other communicative methods to
purposefully threaten, coerce, intimidate, harass, and/or humiliate a person.
j.
2. Category B
a. “Attempted Suicide” means a physical attempt by a person that results in
emergency room treatment, in-patient observation, or hospital admission.
b. “Death Other Than Accidental or Suspicious Death” means the death of a person
by natural cause without suspicious circumstances.
c. “Medical Emergency” means an incident where emergency medical intervention is
required to save a person’s life (e.g. choking relief techniques such as back blows,
Licking County Board of Developmental Disabilities
Administrative Policy Manual
Policy: Incidents Adversely Affecting
Health & Safety
Board Approved: 4/96
Revised: 2/02, 2/07, 5/14
Reviewed: 06/10
Section: 3.2
Page 6 of 11
abdominal thrusts, cardiopulmonary resuscitation, epinephrine auto injector
(Epipen) usage, or intravenous administration of fluids for dehydration).
d. “Missing Person” means an incident that is not considered neglect and a person’s
whereabouts, after immediate measures taken, are unknown and the person is
believed to be at risk, or pose an imminent risk of harm to self or others. An
incident when a person’s whereabouts are unknown for longer than the period of
time specified in the individual service plan that does not result in an imminent risk
of harm to self or others shall be investigated as an unusual incident.
e. “Significant Injury” means an injury of known or unknown cause that is not
considered abuse or neglect, and that results in concussion, broken bone,
dislocation, second or third degree burns, or that requires immobilization, casting or
five or more sutures. Significant injuries shall be designated in the ITS as either
“known” or “unknown” cause.
3. Category C
a. “Law Enforcement” means any incident that results in the person served being
arrested, charged or incarcerated.
b. “Unapproved Behavior Support” means the use of an aversive strategy or
intervention prohibited by OAC 5123:2-1-02 (J) or an aversive strategy
implemented without approval by the Human Rights Committee or Behavior
Support Committee or without informed consent, that results in a likely risk to the
person’s health and welfare. An aversive strategy or intervention prohibited by
OAC 5123:2-1-02 (J) that does not pose a likely risk to health and welfare shall be
investigated as an unusual incident.
c. “Unscheduled Hospitalization” means any hospital admission that is not scheduled
unless the hospital admission is due to a pre-existing condition that is specified in
the individual service plan indicating the specific symptoms and criteria that require
hospitalization.
H. “Ohio Administrative Code (OAC)” means rules passed by the various State of Ohio
administrative agencies.
I. “Ohio Revised Code (ORC)” means statues/laws passed by the legislature of the State of
Ohio.
Licking County Board of Developmental Disabilities
Administrative Policy Manual
Policy: Incidents Adversely Affecting
Health & Safety
Board Approved: 4/96
Revised: 2/02, 2/07, 5/14
Reviewed: 06/10
Section: 3.2
Page 7 of 11
J. “Primary Person Involved (PPI)” means the person alleged to have committed, or to have
been responsible for, the accidental or suspicious death, exploitation, failure to report,
misappropriation, neglect, physical abuse, prohibited sexual relations, rights code violation,
sexual abuse, and/or verbal abuse.
K. “Provider” means an agency provider or independent provider that provides specialized
services.
L. “Specialized Services” means any program or service designed and operated to serve
primarily persons, including a program or service provided by an entity licensed or certified
by the Ohio Department of Developmental Disabilities.
M. “Unusual Incident (UI)” means an event or occurrence involving a person that is not
consistent with routine operations, policies and procedures, or the person’s care or
individual service plan, but is not a major unusual incident (MUI). Unusual incident
includes, but is not limited to:
1. Dental injury;
2. Falls;
3. An injury that is not a significant injury; Medication errors without a likely risk to
health and/or welfare;
4. Overnight relocation of a person due to a fire, natural disaster, or mechanical failure;
5. An incident involving two persons served that is not a Peer-to-Peer Act major unusual
incident; and
6. Rights Code Violations or Unapproved Behavior Support without a likely risk to health
and/or welfare.
N. “Working Day” means Monday, Tuesday, Wednesday, Thursday, or Friday, except when
that day is a holiday as defined in ORC 1.14.
The Board requires its staff to fully cooperate with investigations conducted by MEORC, or any
other investigative entity with authority. Staff will respond to all requests for information made by
MEORC, the Ohio Department of Developmental Disabilities, or any other investigative entity
within five working days of the request. Consequences for failure to comply with this requirement
are detailed in section 6.1 of the Board’s Personnel Policy Manual.
Licking County Board of Developmental Disabilities
Administrative Policy Manual
Policy: Incidents Adversely Affecting
Health & Safety
Board Approved: 4/96
Revised: 2/02, 2/07, 5/14
Reviewed: 06/10
Section: 3.2
Page 8 of 11
REPORTING REQUIREMENTS
All Board and provider staff are mandatory reporters of any incidents or situations that meet the
definition of a major unusual incident as defined by OAC 5123:2-17-02 and this policy. Failure to
report a suspected major unusual incident is a Major Unusual Incident. Staff who are suspected of
having failed to report a potential major unusual incident of which they had knowledge are subject
to disciplinary action up to and including termination of employment consistent with section 6.1 of
the Board’s personnel policy manual.
Failure to report is filed as a Major Unusual Incident when one of the following elements has been
met:
1. A person has suffered any wound, injury or disability or condition of such a nature as to
reasonably indicate abuse or neglect of that person.
Or
2. A person faces a substantial risk of suffering any wound, injury or disability or
condition of such a nature as to reasonably indicate abuse or neglect of that person.
Board and provider staff that do not report situations described above may be prosecuted criminally
by the Licking County Prosecutor’s office. In addition, placement of Board and provider staff on
the Abuser Registry is a potential outcome of failure to report.
Placement on the abuser registry is pursued by the Ohio Department of Developmental Disabilities
when Board and provider staff licensed or certified by the Ohio Department of Developmental
Disabilities unreasonably fails to make a report pursuant to ORC 5123.61 when the staff knew or
should have known that the failure would result in a substantial risk of harm to a person with
developmental disabilities (ORC 5123.51(C)(3)(a)(vii).
The Board and each agency contracting with the Board that provides specialized services will
provide its staff with a written notice, prescribed by the Ohio Department of Developmental
Disabilities, explaining the conduct, delineated below in numbers 1 through 5, that may result in
placement on the Abuser Registry. This written notice will be provided annually (ORC 5123.52):
1. Abuse. Abuse includes the use of any physical force that could reasonably be expected to
result in physical harm. Abuse includes unlawful sexual conduct (unprivileged intercourse
or other sexual penetration) and unlawful sexual contact (unprivileged touching of
another’s erogenous zone).
Abuse includes verbal abuse. Verbal abuse means purposely using words to threaten,
coerce, intimidate, harass or humiliate an individual.
Licking County Board of Developmental Disabilities
Administrative Policy Manual
Policy: Incidents Adversely Affecting
Health & Safety
Board Approved: 4/96
Revised: 2/02, 2/07, 5/14
Reviewed: 06/10
Section: 3.2
Page 9 of 11
2. Prohibited Sexual Relations. This means the consensual touching of an erogenous zone
for sexual gratification by a staff member to a person in the staff member’s care who is
not the staff’s spouse.
3. Neglect. Neglect means, when there is a duty to do so, failing to provide a person with
any treatment, care, goods or services necessary to maintain the health or safety of the
person.
4. Misappropriation (theft). This means obtaining the property of a person or people,
without consent, with an aggregate (combined) value of at least $100. Theft of any check,
credit card, ATM card and the like are also Abuser Registry offenses.
5. Failure to Report Abuse, Neglect or Misappropriation. A staff member of a county
board may be placed on the Abuser Registry if the staff unreasonably does not report
abuse, neglect or misappropriation of the property of an person with developmental
disabilities, or the substantial risk to such a person of abuse, neglect or misappropriation,
when the staff member should know that his/her non-reporting will result in a substantial
risk of harm to such person.
An employee that does not receive the required notice is not exempted from inclusion on the
Abuser Registry.
CONFIDENTIALITY
Reports, records and investigative materials gathered pursuant to reports made under Section
5123.61 of the Ohio Revised Code, OAC 5123: 2-17-02 and this Policy are not public records as
defined in Section 149.43 of the Ohio Revised Code. These records are confidential and will be
released only when subpoenaed by a court.
The Board and/or MEORC MUI will not review, copy, or include in any report the personnel
records of a Board or provider staff member that are confidential under state or federal statutes or
rules, including medical and insurance records, workers' compensation records, employment
eligibility verification (I-9) forms, and social security numbers.
The Board and/or MEORC MUI may review, but not copy, personnel records for Board and
provider staff that include confidential information about the staff member such as payroll records,
performance evaluations, disciplinary records, correspondence regarding status of employment, and
criminal records checks. The Board and MEORC MUI may include in investigative reports
information about the results of the review of personnel records.
The Board and MEORC MUI may review and copy personnel records prepared in connection with
the Board and any Provider's daily operations, such as training records, timesheets, and work
schedules.
Licking County Board of Developmental Disabilities
Administrative Policy Manual
Policy: Incidents Adversely Affecting
Health & Safety
Board Approved: 4/96
Revised: 2/02, 2/07, 5/14
Reviewed: 06/10
Section: 3.2
Page 10 of 11
At the request of the Ohio Department of Developmental Disabilities, the Provider, including the
Board as Provider, will make available to the Ohio Department of Developmental Disabilities
copies of personnel records that are not considered confidential.
The Provider, including the Board as Provider, may redact any confidential information contained
in a personnel or other record before copies are provided to the MEORC investigative agent or the
Ohio Department of Developmental Disabilities.
MEMORANDUM OF UNDERSTANDING
Section 5126.058 of the Ohio Revised Code requires mandated subscribers to enter into a
Memorandum Of Understanding concerning the reporting, processing and coordination of reports
of abuse, neglect and exploitation of persons with developmental disabilities. The purpose of the
Memorandum of Understanding is to define the responsibilities and interrelationship among
participating agencies responsible for providing treatment, handling, coordinating, investigating,
and prosecuting Major Unusual Incidents. The Memorandum of Understanding is also intended to
define responsibilities in criminal and administrative investigations.
ORC 5126.058 (A) (3) to (A) (8) identifies the following parties as mandated subscribers to the
Memorandum Of Understanding:
1.
2.
3.
4.
5.
6.
7.
8.
The Superintendent of the County Board of Developmental Disabilities or designee;
The probate judge or representative;
County peace officer;
All chief municipal peace officers within the County;
Other law enforcement officers handling abuse, neglect, and exploitation of persons
with developmental disabilities;
The county prosecuting attorney;
The county children services agency; and
The County Coroner.
The purpose of the Memorandum of Understanding is to define the responsibilities and
interrelationship among participating agencies responsible for handling, coordination,
investigating, prosecuting, and treatment and to define responsibilities in a criminal and an
administrative investigation. The Memorandum of Understanding should accomplish the
following:
Licking County Board of Developmental Disabilities
Administrative Policy Manual
Policy: Incidents Adversely Affecting
Health & Safety
Board Approved: 4/96
Revised: 2/02, 2/07, 5/14
Reviewed: 06/10
Section: 3.2
Page 11 of 11
1.
2.
3.
4.
5.
6.
7.
The establishment of procedures to be employed by officials in the execution of
their respective responsibilities under ORC Sections 313.12, 2151.421, 2903.16,
5126.058, 5126.31, and 5126.33;
The prompt reporting of incidents of suspected or actual abuse, neglect and
exploitation;
The completion of thorough investigations of suspected abuse, neglect, and
exploitation.
The initiation of appropriate referrals in order to protect persons with
developmental disabilities.
The elimination of unnecessary interviews of persons who are the subject of reports
abuse, neglect and exploitation.
The protection of persons and family members from further trauma by
elimination of duplicative efforts and prevention of gaps in protection and aid; and
The rapid prosecution of the perpetrators of abuse, neglect and exploitation.
STAFF TRAINING
Providers, including independent providers will regularly, at the time of new staff orientation and at
least annually thereafter, educate themselves and staff in their employ on the requirements of OAC
5123:2-17-02 and the specific responsibilities delegated to them.
1.
Direct service staff will receive this education before they have unsupervised contact
with eligible persons, but no later than thirty (30) calendar days after begin their
employment;
2.
Staff that performs duties other than direct service will receive this education within
ninety (90) days after their employment begins;
3.
Annual education for all staff will include a review of any Health and Welfare alerts
disseminated by DoDD in the previous year.
For the Board, The Director of Human Resources will monitor compliance with this required
education for Board staff.
MEORC is responsible for assuring that the training/education requirements for their staff are met.