Subchapter R. PROCEDURES FOR SURROGATE
HEALTH CARE DECISION MAKING
GENERAL PROVISIONS
Sec.
6000.1001. Scope.
6000.1002. Purpose.
6000.1003. Definitions.
HEALTH CARE DECISION MAKING
6000.1011. Competent Individuals.
6000.1012. Individuals who are not competent and need emergency treatment.
6000.1013. Individuals who are not competent and who do not have end-stage medical conditions or are not permanently unconscious.
6000.1014. Individuals who are not competent and who have either end-stage medical conditions or are permanently unconscious.
6000.1015. Health care power of attorney.
6000.1016. Limitations on authority of the surrogate health care decision maker.
6000.1017. Guidance for individuals without family or an advocate.
6000.1018. Intermediate Care Facility for the Mentally Retarded (ICF/MR) facility director as a guardian.
RECORDS
6000.1021. Access to records.
STATUTES
6000.1031. Applicable statutes.
6000.1032. Applicability of section 417(c) of the MH/MR Act to health-care decisions.
Source
The provisions of this Subchapter R adopted January 14, 2011, effective January 15, 2011, 41 Pa.B. 352, unless otherwisse noted.
GENERAL PROVISIONS
§ 6000.1001. Scope.
Administrative entity administrators and directors, county MH/MR administrators, supports coordination organization directors and providers of MR services may consider this subchapter with respect to the decisions of surrogate health care decision makers identified under law of the Commonwealth.
§ 6000.1002. Purpose.
The purpose of this subchapter is to clarify surrogate health care decision making procedures applicable to individuals with MR who are 18 years of age or older in light of Act 169 and other applicable law.
§ 6000.1003. Definitions.
The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.
Act 169—Act 2006-169, which added 20 Pa.C.S. Chapter 54 (relating to health care).
Act 28 facility—A nursing home, personal care home, domiciliary care home, community residential facility, State-operated intermediate care facility for the mentally retarded, privately operated intermediate care facility for the mentally retarded, adult daily living center, home health agency or home health service provider whether licensed or not. See 18 Pa.C.S. § 2713 (relating to neglect of care-dependent person).
Advance health care directive—The term as defined in 20 Pa.C.S. § 5422 (relating to definitions). An advance health care directive is a signed and witnessed document which directs health care in the event that the individual (the principal) is incompetent and has an end-stage medical condition or is permanently unconscious. It also may designate a person to carry out the individual’s wishes regarding health care at the end of life.
CPR—Cardiopulmonary Resuscitation—The term as defined in 20 Pa.C.S. § 5422.
Competent—The term as defined in 20 Pa.C.S. § 5422. Under Act 169, the attending physician determines competency.
DNR Order—Do not resuscitate order—An order in the individual’s medical record that CPR should not be provided to the individual.
End stage medical condition—The term as defined in 20 Pa.C.S. § 5422.
Facility director—
(i) For those facilities that are MR facilities as defined in the MH/MR Act, the facility director is the administrative head of a facility.
(ii) In facilities licensed under Chapter 6400 (relating to community homes for individuals with mental retardation), the term means the chief executive officer under § 6400.43 (relating to chief executive officer).
(iii) In facilities licensed under Chapter 6500 (relating to family living homes), the term means the chief executive officer under § 6500.42 (relating to chief executive officer).
(iv) In intermediate care facilities for persons with mental retardation, the term means the administrator appointed under 42 CFR 483.410(a)(3) (relating to condition of participation: governing body and management).
(v) In facilities licensed under Chapter 5310 (relating to community residential rehabilitation services for the mentally ill), the term means the director selected under § 5310.11 (relating to governing body).
(vi) In facilities licensed under Chapter 5320 (relating to requirements for long-term structured residence licensure), the term means the program director selected under § 5320.22 (relating to governing body).
Health care—The term as defined in 20 Pa.C.S. § 5422.
Health care agent—The term as defined in 20 Pa.C.S. § 5422.
Health care decision—The term as defined in 20 Pa.C.S. § 5422.
Health care power of attorney—The term as defined in 20 Pa.C.S. § 5422. A health care power of attorney is the actual document declaring an individual to make health care decisions for the principal. The person designated in a health care power of attorney is sometimes referred to as the ‘‘health care agent.’’
Health care provider—The term as defined in 20 Pa.C.S. § 5422.
Health care representative—The term as defined in 20 Pa.C.S. § 5422. In addition, Act 169 specifies the following limitation on designation of the health care representative: Unless related by blood, marriage or adoption, a health care representative may not be the principal’s attending physician or other health care provider, not an owner, operator or employee of a health care provider in which the principal receives care.
lncompetent—The term as defined in 20 Pa.C.S. § 5422.
Living will—The term as defined in 20 Pa.C.S. § 5422.
MH/MR Act—The Mental Health and Mental Retardation Act of 1966 (50 P. S. § § 4101—4704).
MH—Mental health.
MR—Mental retardation.
Mental health advance directive—A document that directs MH services and supports that an individual might want to receive during a crisis if the individual is unable to make decisions because of the individual’s mental illness. This is a separate document from an advance health care directive. See 20 Pa.C.S. Chapter 58 (relating to mental health care).
Permanently unconscious—The term as defined in 20 Pa.C.S. § 5422.
Person—The term as defined in 1 Pa.C.S. § 1991 (relating to definitions).
Principal—The term as defined in 20 Pa.C.S. § 5422. The principal is at least 18 years of age, has graduated from high school, has married or is an emancipated minor.
Surrogate health care decision maker—A person that makes health care decisions for another individual.
HEALTH CARE DECISION MAKING
§ 6000.1011. Competent individuals.
(a) The health care or end of life decisions of an individual who is competent should be honored.
(b) Competent individuals may also execute advance health care directives in accordance with 20 Pa.C.S. Chapter 54 (relating to health care).
(c) Competent individuals should be encouraged to make advance health care directives which will become operative if they lose competency unless revoked in accordance with 20 Pa.C.S. Chapter 54.
(d) Advance health care directives should be reviewed and updated in writing periodically.
§ 6000.1012. Individuals who are not competent and need emergency treatment.
Consent is implied in law for emergencies and there is no need to seek a surrogate health care decision maker before providing emergency medical treatment. See the Medical Care Availability and Reduction of Error (MCARE) Act (40 P.S. § § 1303.101—1303.1115); In re Dorone, 534 A.2d 452 (Pa. 1987).
§ 6000.1013. Individuals who are not competent and who do not have end-stage medical conditions or are not permanently unconscious.
(a) If an individual is not competent to make a particular nonemergent health care decision, another person must make that decision on the individual’s behalf.
(b) Under Act 169, when a guardian, health care agent or health care representative will be making the decision, the attending physician determines whether an individual has an end stage medical condition or is permanently unconscious.
(c) When a surrogate health care decision maker is needed to make a nonemergent health care decision for an individual who neither has an end-stage medical condition nor is permanently unconscious, the health care decision maker should be chosen in the following order:
(1) Health care agent. If the individual, while competent, has executed a valid advance health care directive that designates a health care agent and the health care agent is available and willing to make the decision, the health care agent should make the health care decision for the individual. See 20 Pa.C.S. Chapter 54, Subchapter C (relating to health care agents and representatives).
(2) Guardian of the individual’s person.
(i) If, under Pennsylvania’s guardianship statute (20 Pa.C.S. Chapter 55 (relating to incapacitated persons)), a court has already appointed a guardian to make health care decisions on the individual’s behalf, the guardian should make those decisions for the individual.
(ii) If a person who executed a valid health care power of attorney is later adjudicated an incapacitated person and a guardian of the person is appointed by the court to make health care decisions, the health care agent named in the health care power of attorney is accountable to both the guardian and the individual.
(iii) The guardian has the same power to revoke or amend the appointment of a health care agent as the individual would have if he were not incapacitated, but may not revoke or amend the instructions in an advance health care directive absent judicial authorization. See 20 Pa.C.S. § 5460(a) (relating to relation of health care agent to court-appointed guardian and other agents).
(3) Health care representative.
(i) In the absence of a health care agent designated under a valid advance health care directive or a court-appointed guardian of the person with authority to make health decisions, an available and willing health care representative should make the health care decision.
(ii) In descending order of priority, the following persons can act as health care representatives for individuals:
(A) A person chosen by the individual (in a signed writing or by informing the individual’s attending physician) while the individual was of sound mind.
(B) The individual’s spouse (unless a divorce action is pending).
(C) The individual’s adult child.
(D) The individual’s parent.
(E) The individual’s adult brother or sister.
(F) The individual’s adult grandchild.
(G) An adult who has knowledge of the individual’s preferences and values. See 20 Pa.C.S. Chapter 54, Subchapter C.
(4) Facility director.
(i) In the absence of any other appointed decision maker or willing next of kin, the facility director becomes the health care decision maker under the MH/MR Act.
(ii) Under the MH/MR Act, the director of a facility may, with the advice of two physicians not employed by the facility, determine when elective surgery should be performed upon any mentally disabled person admitted or committed to the facility when the person does not have a living parent, spouse, issue, next of kin or legal guardian as fully and to the same effect as if the director had been appointed guardian and had applied to and received the approval of an appropriate court therefor.
(iii) Section 417(c) of the MH/MR Act (50 P.S. § 4417(c)) specifies that the facility director may authorize elective surgery, but the Department has consistently interpreted that section to recognize that the facility director’s authority also encompasses health care decisions generally.
(iv) The facility director may authorize elective surgery and other treatment only with the advice of two physicians not employed by the facility.
(v) When the facility director becomes the surrogate health care decision maker for an individual who does not have an end-stage medical condition or is not permanently unconscious, the director should first review the individual’s support plan and relevant medical history and records to help identify the individual’s medical status historically and immediately prior to making a surrogate health care decision.
(vi) The facility director should be informed of the decision to be made and gather information based on the direct knowledge of those familiar with the individual.
(vii) In this manner, the facility director will have sufficient information to make the decision that the individual would make if able to do so.
(viii) Even when another surrogate health care decision maker is identified, the facility director should continue to monitor the situation to ensure that decisions are made with the best interest of the individual as the paramount concern.
(ix) In the event of a short-term absence of the facility director, the director may assign a designee to perform these functions.
(x) The assigned designee may only be a person authorized to perform the facility director’s functions in the director’s absence.
(xi) The facility director may not authorize a DNR order for a person who is not competent and does not have an end-stage medical condition.
§ 6000.1014. Individuals who are not competent and who have either end-stage medical conditions or are permanently unconscious.
(a) Under Act 169, when a guardian, health care agent or health care representative will be making the decision, the attending physician determines whether an individual has an end stage medical condition or is permanently unconscious.
(b) In contrast, the MH/MR Act, which applies to health care decisions by facility directors, requires the advice of two physicians for recommended treatment of health care conditions, including end stage medical conditions.
(c) When a surrogate health care decision maker is needed to make a nonemergent health care decision for an individual who has an end-stage medical condition or is permanently unconscious and who has not executed a valid living will that governs the decision, the surrogate health care decision maker should be chosen in the following order:
(1) Health care agent. If the individual, while competent, has executed a valid advance health care directive that designates a health care agent and the health care agent is available and willing to make the decision, the health care agent should make health care decisions for the individual.
(2) Guardian of the individual’s person.
(i) If, under Pennsylvania’s guardianship statute, a court has already appointed a guardian of the person to make health care decisions on the individual’s behalf, the guardian should make the decisions for the individual.
(ii) If a person who executed a valid health care power of attorney is later adjudicated an incapacitated person and a guardian of the person is appointed by the court to make medical decisions, the health care agent named in the health care power of attorney is accountable to both the guardian and the individual.
(iii) The guardian has the same power to revoke or amend the appointment of a health care agent as the individual would have if he were not incapacitated, but may not revoke or amend the instructions in an advance health care directive absent judicial authorization.
(3) Health care representative.
(i) In the absence of a health care agent designated under a valid advance health care directive or a court-appointed guardian of the person with authority to make health care decisions, an available and willing health care representative should make the health care decision.
(ii) In descending order of priority, the following individuals can act as health care representatives for individuals:
(A) A person chosen by the individual (in a signed writing or by informing the individual’s attending physician) while the individual was of sound mind.
(B) The individual’s spouse (unless a divorce action is pending).
(C) The individual’s adult child.
(D) The individual’s parent.
(E) The individual’s adult brother or sister.
(F) The individual’s adult grandchild.
(G) An adult who has knowledge of the individual’s preferences and values.
(4) Facility director.
(i) In the absence of any other appointed decision maker or willing next of kin, the facility director in his discretion becomes the surrogate health care decision maker under section 417(c) of the MH/MR Act.
(ii) Section 417(c) of the MH/MR Act specifies that the facility director may authorize elective surgery, but the Department has consistently interpreted that section to recognize that the facility director’s authority also encompasses health care decisions generally.
(iii) The facility director may authorize elective surgery and other treatment only with the advice of two physicians not employed by the facility.
(iv) When the facility director becomes the surrogate health care decision maker for an individual who has an end-stage medical condition or is permanently unconscious, the director shall first review the individual’s support plan and relevant medical history and records to help identify the individual’s medical status historically and immediately prior to making a surrogate health care decision.
(v) The facility director must be informed of the decision to be made and gather information based on the direct knowledge of those familiar with the individual.
(vi) In this manner, the facility director will have sufficient information to make the decision that the individual would make if able to do so.
(vii) For a decision to withdraw treatment or life-sustaining care for a person who is not competent who has an end-stage medical condition or is permanently unconscious, the Department recommends a facility director seek judicial authorization prior to the withdrawal of treatment or life-sustaining care due to a risk of conflict of interest claims.
(viii) For a DNR order for a person who is not competent who has an end-stage medical condition or is permanently unconscious, the Department recommends a facility director seek judicial authorization prior to requesting the issuance of a DNR order due to a risk of conflict of interest claims.
(ix) Pending the judicial authorization under subparagraphs (vii) and (viii), the Department recommends a facility director direct that treatment or life-sustaining care be continued for a person who is not competent who has an end-stage medical condition or is permanently unconscious.
(x) Even when another surrogate health care decision maker is identified, the facility director should continue to monitor the situation to ensure that decisions are made with the best interest of the individual as the paramount concern.
(xi) In the event of a short-term absence of the facility director, the director may assign a designee to perform these functions.
(xii) The assigned designee may only be a person authorized to perform the facility director’s functions in the director’s absence.
(d) In the rare circumstance that the individual with an end-stage medical condition or who is permanently unconscious does not have a living will, health care agent, court-appointed guardian, available and willing health care representative or facility director, then a court should appoint a guardian with authority to act. Appropriate medical care should be provided pending the appointment of a guardian.
(e) In reaching decisions about appropriate care, the following may be helpful:
(1) Holding a team meeting including the health care provider, the family/health care representative, the mental retardation service provider and any other interested parties to clarify the issues and each party’s understanding of the situation.
(2) Involving the palliative care team, the patient advocate, or both, at a hospital to act as an objective party and help communicate issues and assist each party in understanding the situation.
(3) Using hospital ethics committees to review situations.
(4) Having a second medical or surgical opinion, which can sometimes clarify the prognosis or possible treatments for a particular condition.
(5) As a last resort, pursuing resolution through the courts.
§ 6000.1015. Health care power of attorney.
(a) Unless otherwise specified in the health care power of attorney, a health care power of attorney becomes operative when the following occurs:
(1) A copy is provided to the attending physician.
(2) The attending physician has determined that the principal is incompetent. See 20 Pa.C.S. § § 5422 and 5454(a) (relating to definitions; and when health care power of attorney operative).
(b) Unless otherwise specified in the health care power of attorney, a health care power of attorney becomes inoperative when, in the determination of the attending physician, the principal is competent.
§ 6000.1016. Limitations on authority of the surrogate health care decision maker.
(a) A surrogate health care decision maker may not execute an advance health care directive or name a health care agent on behalf of an incompetent individual.
(b) Under 20 Pa.C.S. Chapter 54 (relating to health care) and applicable case law (see In re D.L.H, 2 A.2d. 505 (Pa. 2010)), neither a health care representative nor a guardian nor a facility director has authority to refuse life-preserving care for a person who has a life-threatening medical condition, but is neither in an end-stage medical condition nor permanently unconscious.
(c) Title 20 Pa.C.S. § 5462(c)(1) (relating to duties of attending physician and health care provider) provides:
‘‘Health care necessary to preserve life shall be provided to an individual who has neither an end-stage medical condition nor is permanently unconscious, except if the individual is competent and objects to such care or a health care agent objects on behalf of the principal if authorized to do so by the health care power of attorney or living will.’’
(d) A residential facility as defined by Act 28 must provide necessary treatment, care, goods or services to an individual except where otherwise permitted under 18 Pa.C.S. § 2713(e) (relating to neglect of care-dependent person) as follows:
(1) The caretaker’s, individual’s, or facility’s lawful compliance with a care-dependent person’s living will as provided in 20 Pa.C.S. Chapter 54.
(2) The caretaker’s, individual’s, or facility’s lawful compliance with a care-dependent person’s written, signed, and witnessed instructions, executed when the care-dependent person is competent as to the treatment he wishes to receive.
(3) The caretaker’s, individual’s or facility’s lawful compliance with the direction of one of the following:
(i) An agent acting under a lawful durable power of attorney under 20 Pa.C.S. Chapter 56 (relating to powers of attorney), within the scope of that power.
(ii) A health care agent acting under a health care power of attorney under 20 Pa.C.S. Chapter 54, Subchapter C (relating to health care agents and representatives), within the scope of that power.
(4) The caretaker’s, individual’s, or facility’s lawful compliance with a DNR order written and signed by the care-dependent person’s attending physician. Generally, a DNR order is appropriate in the presence of an end-stage medical condition.
(5) The caretaker’s, individual’s, or facility’s lawful compliance with the direction of a care-dependent person’s health care representative under 20 Pa.C.S. § 5461 (relating to decisions by health care representative), provided the care dependent person has an end-stage medical condition or is permanently unconscious as these terms are defined in 20 Pa.C.S. § 5422 (relating to definitions) as determined and documented in the person’s medical record by the person’s attending physician.
§ 6000.1017. Guidance for individuals without family or an advocate.
(a) For individuals that may not have living family members or anyone that is currently advocating for them, the county or administrative entity, supports coordination organization, or the provider agency working with the individual should help the individual identify someone who knows the individual and would be willing to act as the individual’s health care representative.
(b) The health care representative may be a friend, a family friend, someone in the individual’s church or neighborhood, or someone that has worked with the individual in the past, but is no longer actively providing their services.
§ 6000.1018. Intermediate Care Facility for the Mentally Retarded (ICF/MR) facility director as a guardian.
The prohibition in 20 Pa.C.S. § 5461(f) (relating to decisions by health care representative) on a health care provider’s being a health care representative is not applicable to a facility director under section 417(c) of the MH/MR Act (50 P.S. § 4417(c)), regarding powers and duties of directors, because a facility director is made a guardian under that section, not a health care representative.
RECORDS
§ 6000.1021. Access to records.
Under the Health Insurance Portability and Accountability Act (HIPAA), guardians, agents or representatives as medical surrogates have the same access to medical records that the principal does. See 45 CFR 164.502(g) and 164.510(b)(3) (relating to uses and disclosures of protected health information: general rules; and uses and disclosures requiring an opportunity for the individual to agree or to object).
STATUTES
§ 6000.1031. Applicable statutes.
Several other statutes also govern health care decision making, and were not repealed by Act 169. Accordingly, they remain in effect. These statutes include the following:
(1) Title 18 Pa.C.S. § 2713 (relating to neglect of care-dependent person).
(2) Title 20 Pa.C.S. Chapter 55 (relating to incapacitated persons).
(3) The Medical Care Availability and Reduction of Error (MCARE) Act (40 P.S. § § 1303.101—1303.115).
(4) Section 417(c) of the MH/MR Act (50 P.S. § 4417(c)), regarding powers and duties of directors.
§ 6000.1032. Applicability of section 417(c) of the MH/MR Act to health-care decisions.
(a) Notwithstanding that section 417(c) of the MH/MR Act (50 P.S. § 4417(c)), regarding powers and duties of directors, explicitly references only ‘‘elective surgery,’’ that section should be read as applicable to health care decisions generally.
(b) A facility director’s authority under section 417(c) of the MH/MR Act should be construed to include authority to make decisions regarding palliative care for persons in an end-stage (terminal) condition.
(c) For care provided in the MR facility itself, no surrogate consent is needed because 18 Pa.C.S. § 2713 (relating to neglect of care-dependent person) requires that necessary care and treatment be provided without it.
(d) For care outside the mental retardation facility, such as a doctor’s office or hospital, the primary care physician (PCP) and the specialist performing the procedure can serve as the two physicians (except in the rare circumstance where the PCP is a payroll employee of the MR facility) required under section 417(c) of the MH/MR Act.
APPENDIX A. [Reserved]
Source
The provisions of this Appendix A adopted August 19, 1988, effective October 1, 1988, 18 Pa.B. 3703; reserved August 9, 1991, effective November 8, 1991, 21 Pa.B. 3595. Immediately preceding text appears at serial pages (131329) to (131333).
APPENDIX B
LICENSING WEIGHTING SYSTEM FOR VOCATIONAL FACILITIES
WEIGHTS OF REGULATIONS
General
Requirements | Subject | Weight | Rounded
Weight |
| 2390.11 | Application | 5.12 | 5 |
| 2390.14(a) | Labor & Industry—Fire Safety Approval | 8.33 | 8 |
| 2390.14(b) | Written Annual Verification | 6.61 | 7 |
| 2390.15(a) | Interstate Commerce—Fed. Wage & Hour Certificate | 5.58 | 6 |
| 2390.15(b) | Intrastate Commerce—State Certificate | 5.30 | 5 |
| 2390.15(c) | Interstate & Intrastate Commerce—Fed./State Certificate | 5.01 | 5 |
| 2390.16 | Public Eating & Drinking Certificate | 7.38 | 7 |
| 2390.17 | Written Statement of Purpose | 4.49 | 4 |
| 2390.18(a) | Unusual Incident Report | 6.87 | 7 |
| 2390.18(a) | Unusual Incident Report—24 hours | 5.78 | 6 |
| 2390.18(b) | Unusual Incident Report—weekend | 5.71 | 6 |
| 2390.19(a) | Abuse—Past 12 months | 8.81 | 9 |
| 2390.19(b) | Abuse Reported—24 hours | 8.64 | 9 |
| 2390.19(c) | Investigated Abuse—24 hours | 7.86 | 8 |
| 2390.19(c) | Abuse Report—Support or Deny Allocation | 7.55 | 8 |
| 2390.19(c) | Implement Change—Prevent Abuse | 8.60 | 9 |
| 2390.19(d) | Criminal Abuse Reported Immediately | 8.76 | 9 |
| 2390.20 | Written Accident Prevention Policy | 7.87 | 8 |
| 2390.21(a) | Discrimination | 7.28 | 7 |
| 2390.21(a) | Civil & Legal Rights | 7.68 | 8 |
| 2390.21(b) | Civil Rights Policy & Procedure | 6.92 | 7 |
| 2390.22(a) | Governing Body | 4.87 | 5 |
| 2390.22(b) | Governing Body—Financial Benefit | 4.08 | 4 |
| 2390.22(c) | Conflict of Interest | 4.21
| 4
|
| 2390.22(d) | Governing Body—Quarterly Meeting | 3.49 | 3 |
| 2390.22(e) | Financial Reports—Review/Approval | 3.82 | 4 |
| 2390.22(f) | Annual Program Report—Review/Approval | 4.12 | 4 |
| 2390.23 | Sound & Ethical Pract. | 4.90 | 5 |
| Staffing | Subject | Weight | Rounded
Weight |
| 2390.32(a) | Chief Executive Officer/Employed | 5.49 | 5 |
| 2390.32(a) | Chief Executive Officer/Designee | 5.33 | 5 |
| 2390.32(b) | Chief Executive Officer/Responsibilities | 6.34 | 6 |
| 2390.32(c) | Chief Executive Officer/Qualifications | 4.60 | 5 |
| 2390.33(a) | 1:45 Program Specialist/Client Ratio | 6.12 | 6 |
| 2390.33(b) | Program Specialist Responsibility | 5.91 | 6 |
| 2390.33(c) | Program Specialist Qualification | 5.21 | 5 |
| 2390.34(a) | One Production Manager | 5.58 | 6 |
| 2390.34(b) | Production Manager Responsibility | 5.26 | 5 |
| 2390.34(c) | Production Manager Qualifications | 4.67 | 5 |
| 2390.35(a) | 1:15 Floor Supervisor Ratio | 6.60 | 7 |
| 2390.35(b) | Floor Supervisor Physically Present | 6.56 | 7 |
| 2390.35(c) | Floor Supervisor Responsibility | 6.95 | 7 |
| 2390.35(d) | Floor Supervisor Qualifications | 5.11 | 5 |
| 2390.36(a) | 1:10 Trainer Ratio | 6.29 | 6 |
| 2390.36(b) | Trainer Responsibilities | 6.00 | 6 |
| 2390.36(c) | Trainer Qualifications | 5.06 | 5 |
| 2390.37(a) | Vocational Evaluator Employed | 5.53 | 6 |
| 2390.37(b) | Vocational Evaluator Responsibilities | 5.40 | 5 |
| 2390.37(c) | Vocational Evaluator Qualifications | 5.09 | 5 |
| 2390.38(a) | Program Specialist & Floor Supervisor (ten or more clients) | 5.67 | 6 |
| 2390.38(b) | Qualifications—2 Staff Positions | 5.40 | 5 |
| 2390.39(a) | 2 Staff Present—10 or More Clients | 6.97 | 7 |
| 2390.39(b) | 1 Staff Present—Fewer than 10 Clients | 7.74 | 8 |
| 2390.39(c) | 1 Qualified Program Specialist—20 or more clients | 5.94 | 6 |
| 2390.40(a) | Orientation for Staff | 6.54 | 7 |
| 2390.40(b) | 24 Hrs Staff Training | 5.42 | 5 |
| 2390.40(c) | Records of Training on file | 4.15 | 4
|
| Physical Site | Subject | Weight | Rounded
Weight |
| 2390.51 | Accommodations for Physically Handicapped | 7.91 | 8 |
| 2390.52(a) | 80 Sq. Ft. Indoor Floor Space | 5.69 | 6 |
| 2390.52(b) | 60 Sq. Ft. Indoor Floor Space | 5.64 | 6 |
| 2390.53 | Outside Walks—Free of Hazards | 8.17 | 8 |
| 2390.54 | Combustible Supplies | 8.59 | 9 |
| 2390.55(a) | Trash Removed—Once/Week | 6.97 | 7 |
| 2390.55(b) | Insects/Rodents | 7.64 | 8 |
| 2390.56 | Hot & Cold Water—Bathroom & Kitchen | 7.87 | 8 |
| 2390.57 | Indoor Temperature—65° F-90° F | 7.22 | 7 |
| 2390.58 | Operable, Non-Coin Telephone | 6.64 | 7 |
| 2390.59 | Emergency Numbers Posted | 7.72 | 8 |
| 2390.60(a) | First Aid Area | 6.50 | 7 |
| 2390.60(b) | First Aid Area/Equipment | 7.12 | 7 |
| 2390.60(c) | First Aid Accessible to Staff | 7.33 | 7 |
| 2390.60(d) | First Aid Kit Contents | 7.32 | 7 |
| 2390.61 | Surfaces—Free of Hazards | 7.36 | 7 |
| 2390.62 | Sanitary Conditions Maintained | 7.79 | 8 |
| 2390.63 | Adequate Lighting | 8.08 | 8 |
| 2390.64 | Well-Secured Handrails | 8.06 | 8 |
| 2390.65 | Interior Stairs—Nonskid Surfaces | 7.65 | 8
|
| General Requirements | Subject | Weight | Rounded
Weight |
| 2390.66 | Landings Provided | 7.33 | 7 |
| 2390.67 | Conditions—Safe & Sanitary | 7.32 | 7 |
| 2390.68 | Hazardous Equipment—Guard & Safety Devices | 8.64 | 9 |
| 2390.69 | Protective Equipment Worn | 8.65 | 9 |
| 2390.70 | Equipment—Visual, Auditory & Tactile Signals | 8.13 | 8 |
| 2390.71(a) | Ventilation | 7.32 | 7 |
| 2390.71(b) | Mechanical Exhaust—Toxic, Dust & Odor | 8.49 | 8 |
| 2390.72(a) | Passages & Work Aisles—& Unobstructed | 7.76 | 8 |
| 2390.72(b) | Work aisles—36 inches wide | 6.45 | 6 |
| 2390.72(c) | Work aisles—marked—2" wide | 5.62 | 6 |
| 2390.72(c) | Visually Handicapped—Tactile Guides | 6.24 | 6 |
| 2390.73 | Elevator—labor & industry approval | 7.88 | 8 |
| 2390.74(a) | Lavatories—physically handicapped | 7.36 | 7 |
| 2390.74(b) | 1:30 Toilet Ratio | 6.44 | 6 |
| 2390.74(c) | Separate Lavatories for Men & Women | 5.92 | 6 |
| 2390.74(d) | Lavatory—Required Equip. | 6.37 | 6 |
| 2390.75(a)(1) | Food Protection & Storage | 8.37 | 8 |
| 2390.75(a)(2) | Food—Proper Temperatures | 8.l7 | 8 |
| 2390.75(a)(3) | Utensils—washed with mechanical dishwasher | 7.24 | 7 |
| 2390.75(a)(4) | Mechanical dishwasher—required temperatures | 7.67 | 8 |
| 2390.75(a)(5) | Mechanical dishwasher—manufacturers instructions | 6.92 | 7 |
| 2390.75(b) | Dining Area | 5.33 | 5 |
| 2390.75(b)(1) | Dining Area Clear | 6.88 | 7 |
| 2390.75(b)(2) | Dining Area—Table & Chairs | 5.82 | 6
|
| Fire Safety | Subject | Weight | Rounded
Weight |
| 2390.81 | Corridors & Exits Unobstructed | 8.42 | 8 |
| 2390.82(a) | Emergency Evacuation Procedures | 7.88 | 8 |
| 2390.82(b) | Fire Safety Inspection or Notification | 7.92 | 8 |
| 2390.83(a) | Operable Fire Alarm | 8.56 | 9 |
| 2390.83(b) | Fire Alarm Checked | 7.94 | 8 |
| 2390.83(b) | Written Record of Fire Alarm Check | 7.01 | 7 |
| 2390.83(c) | Notification for Repair 24 Hours | 7.85 | 8 |
| 2390.83(c) | Written Procedure—Fire Safety | 7.58 | 8 |
| 2390.84(a) | 10 ABC Fire Extinguishers | 8.14 | 8 |
| 2390.84(b) | Fire Extinguishers—100 Feet | 7.86 | 8 |
| 2390.84(c) | 10B Fire Extinguishers—Kitchen | 8.24 | 8 |
| 2390.84(d) | Fire Extinguisher Under 45 Pounds—Mounted | 7.59 | 8 |
| 2390.84(e) | Fire Extinguisher Over 45 Pounds—Wheeled Unit | 7.42 | 7 |
| 2390.84(f) | Fire Extinguisher—Accessible | 8.14 | 8 |
| 2390.84(g) | Fire Extinguisher—Inspection & Approval | 8.04 | 8 |
| 2390.85(a) | Fire Drill—Every 90 Days | 7.73 | 8 |
| 2390.85(a) | Written Fire Drill Record | 6.45 | 7 |
| 2390.85(b) | Fire Drills—Different Times | 6.31 | 6 |
| 2390.85(b) | Hypothetical Location—Different | 6.44 | 6 |
| 2390.85(c) | Clients Evacuation—Fire Drill | 7.40 | 7 |
| 2390.85(d) | Fire Alarms Tested | 7.56 | 8 |
| 2390.86 | Signs—EXIT—Plain and Legible | 7.90 | 8 |
| 2390.86 | Exits Marked | 7.83 | 8 |
| 2390.86 | Exits Sign Letters—3/4 Inches Wide | 6.76 | 7 |
| 2390.86 | Tactile Exit Markings | 7.18 | 7 |
| 2390.87 | Instructed in General Fire Safety | 7.40 | 7 |
| Program | Subject | Weight | Rounded
Weight |
| 2390.91 | Activities for Clients | 5.99 | 6 |
| 2390.91 | Individual Written Program Plan Provided | 5.94 | 6 |
| 2390.92 | 20% Remunerative Work | 5.29 | 5 |
| 2390.93 | Work Training—Development Program | 5.54 | 6 |
| 2390.94(a) | Written Assessment—20 Days | 5.24 | 5 |
| 2390.94(b) | Initial Assessment by Program Specialist or Vocational
Evaluator | 5.10 | 5 |
| 2390.94(c) | Copy of Initial Assessment | 4.92 | 5 |
| 2390.94(d)(1) | Document of Client’s Disability | 6.40 | 6 |
| 2390.94(d)(2) | Level of Vocational Functioning | 5.55 | 6 |
| 2390.94(d)(3) | Vocational Interests | 5.17 | 5 |
| 2390.94(d)(4) | Ability for Instructions | 5.95 | 6 |
| 2390.94(d)(5) | Recommendations for Specific Areas of Training | 5.76 | 6
|
General
Requirements | Subject | Weight | Weight |
| 2390.94(e) | Written Statement Signed | 5.14 | 5 |
| 2390.95(a) | Individual Written Program Plan (IWPP) Developed—
30 Days | 5.62 | 6 |
| 2390.95(b) | IWPP Developed—Interdisciplinary Team | 5.44 | 5 |
| 2390.95(b) | IWPP—Signature and Dated—Interdisciplinary Team | 4.44 | 4 |
| 2390.96(1) | IWPP—Short Term Objectives | 5.60 | 6 |
| 2390.96(2) | IWPP—Current Skill Level | 5.63 | 6 |
| 2390.96(3) | IWPP—Time Frames | 5.13 | 5 |
| 2390.96(4) | IWPP—Method of Evaluation | 5.21 | 5 |
| 2390.96(5) | IWPP—Service Areas | 5.27 | 5 |
| 2390.96(6) | IWPP—Staff Responsible | 5.42 | 5 |
| 2390.96(7) | IWPP—Placement Potential | 5.23 | 5 |
| 2390.97(a) | IWPP—Reviewed and Updated—65 days | 5.24 | 5 |
| 2390.97(b) | IWPP—Reviewed and Updated—20 days | 4.95 | 5 |
| 2390.97(c) | IWPP—Signed by Program Specialist & Client | 5.40 | 5 |
| 2390.97(d) | IWPP—Reviewed and Rewritten Annually | 5.77 | 6 |
| 2390.97(d) | IWPP—Signed and Dated Revised IWPP | 4.65 | 5 |
| 2390.98(a) | IWPP—Copy in Client’s File | 5.18 | 5 |
| 2390.98(b) | IWPP—Invitation to Client or Parent | 4.96 | 5 |
| 2390.98(c) | IWPP—Provided Copy | 4.81 | 5 |
| 2390.99 | IWPP—Client Needs Met | 5.73 | 6 |
| 2390.100(1) | Vocational Evaluation by Vocational Evaluator | 5.24 | 5 |
| 2390.100(2) | Vocational Evaluation in Client’s File | 5.19 | 5 |
| 2390.100(3)(i) | Vocational Evaluation of Client’s Vocational Level | 5.44 | 5 |
| 2390.100(3)(ii) | Vocational Evaluation—Include Employers Objectives | 5.23 | 5 |
| 2390.100(3)(iii) | Vocational Evaluation—Include Vocational Interests | 5.15 | 5 |
| 2390.100(3)(iv) | Vocational Evaluation—Include Client’s Personal &
Social Adjustment Level | 5.40 | 5 |
| 2390.100(3)(v) | Vocational Evaluation—Work Attitude | 5.31 | 5 |
| 2390.100(3)(vi) | Vocational Evaluation—Include Fatigue Level | 5.88 | 6 |
| 2390.100(3)(vii) | Vocational Evaluation—Include Client’s Ability to
Follow Instructions | 6.08 | 6 |
| 2390.100(3)(viii) | Vocational Evaluation—Recommendation for Specific
Areas | 5.72 | 6 |
| 2390.100(4) | Vocational Evaluation—Signed Statement | 5.37 | 5 |
| Health | Subject | Weight | Rounded
Weight |
| 2390.101 | Communicable Disease | 8.37 | 8 |
| 2390.102 | First Aid Technique—1 Certified Staff Member | 8.15 | 8 |
| 2390.103 | Written Emergency Medical Plan | 7.92 | 8 |
| 2390.104 | Emergency Information Accessible | 8.27 | 8 |
| 2390.104 | Emergency Medical Information | 8.32 | 8 |
Admission
and
Placement
| Subject | Weight | Rounded
Weight |
| 2390.111(a) | Client—Preadmission Interview | 5.24 | 5 |
| 2390.111(b) | Notification—30 Days | 4.41 | 4 |
| 2390.111(b) | Notification—Specify Service and Reason for Decision | 4.62 | 5 |
| 2390.111(c) | Kept on File for 3 Years | 3.36 | 3 |
| 2390.112(a) | Clients Oriented to Facility | 6.27 | 6 |
| 2390.112(a) | Orientation Date—Client’s Record | 4.21 | 4 |
| 2390.112(b) | Written Information Upon Admission | 5.81 | 6 |
| 2390.112(b) | Written Statement in Client’s Record | 5.17 | 5 |
| 2390.113(b) | Arrangements for Placement Services | 5.94 | 6 |
| 2390.113(b) | Placement Services—Staff Responsibility | 5.46 | 5 |
| 2390.113(c)(1) | Placement Services—Employer Information | 5.54 | 6 |
| 2390.113(c)(2) | Placement Services—Notification | 5.56 | 6 |
| 2390.113(c)(3) | Placement Services—Client Participation | 5.95 | 6 |
| 2390.113(c)(4) | Placement Services—Clients Abilities | 6.29 | 6 |
| 2390.113(c)(5) | Placement Services—Follow-Up Activities | 6.47 | 6 |
| 2390.113(d) | Documents of Competitive Employment | 5.08 | 5 |
| 2390.113(e) | Placement Services Component Written | 4.67 | 5
|
| Client Records | Subject | Weight | Rounded
Weight |
| 2390.121 | Individual Record | 6.44 | 6 |
| 2390.121 | Legible, Dated and Signed | 5.81 | 6 |
| 2390.122 | Records Kept at Facility | 6.01 | 6 |
| 2390.122 | Records Kept 3 Years | 4.23 | 4 |
| 2390.123 | Confidential & Locked | 6.87 | 7 |
| 2390.124 | Information—Records | 6.60 | 7 |
| 2390.125 | Policy on Access to Records | 5.89 | 6 |
| 2390.126(a) | Client/Parent/Guardian Access | 6.01 | 6 |
| 2390.126(b) | Facility Responsible | 6.32 | 6 |
| 2390.127 | Written Consent—Release of Information | 6.46 | 6 |
| Handicapped Employment | Subject | Weight | Rounded
Weight |
| 2390.141 | Written Documentation—Individual Client | 5.16 | 5 |
| 2390.143(a) | Completed Work Performance Review | 5.30 | 5 |
| 2390.143(b)(1) | Work Performance Review Quantity and Quality | 5.30 | 5 |
| 2390.143(b)(2) | Work Performance Review Changes in Production | 5.07 | 5 |
| 2390.143(b)(3) | Upward Movement to Competitive Employment | 5.41 | 5 |
| 2390.143(b)(4) | Work Related Problems | 5.53 | 6 |
| 2390.143(c) | Copy Provided | 4.93 | 5 |
| 2390.144 | 1:20 Floor Supervisor Ratio | 6.41 | 6
|
Source
The provisions of this Appendix B adopted August 19, 1988, effective October 1, 1988, 18 Pa.B. 3703.
Cross References
This appendix cited in 55 Pa. Code § 6000.311 (relating to computation of weighted score).
Source
The provisions of this Appendix C adopted August 19, 1988, effective October 1, 1988, 18 Pa.B. 3715.
Source
The provisions of this Appendix D adopted August 19, 1988, effective October 1, 1988, 18 Pa.B. 3715.
APPENDIX E
INCIDENT MANAGEMENT COMPONENTS
PROVIDERS/ENTITIES ARE TO:
• Promote the health, safety, rights and enhance the dignity of individuals receiving services.
• Develop provider-specific policy/procedures for incident management.
• Ensure that staff and others associated with the individual have proper orientation and training to respond to, report and prevent incidents.
• Provide ongoing training to individuals and families on the recognition of abuse and neglect.
• Ensure when incidents occur that affect a person’s health, safety or rights, that the people who are present:
— Take prompt action to protect the person’s health, safety and rights. This includes separation of the target when the individual’s health and safety are jeopardized. This separation shall continue until an investigation is completed. In addition, the target shall not be permitted to work directly with any other service recipient during the investigation process. When the target is another individual receiving supports or services, and complete separation is not possible, the provider shall institute additional protections.
— Notify the responsible person designated in provider policy.
• Assign trained individual(s) Point Person(s) to whom incidents are reported when they occur and who will make certain that all immediate steps to assure health and safety have been implemented and follow the incident through closure.
• Contact appropriate law enforcement agencies when there is suspicion that a crime has occurred.
• Comply with all applicable laws, regulations and policies.
• Conduct certified investigations.
• Analyze the quality of investigations.
• Respond to concerns from individuals/family about the reporting and investigation processes.
• Inform the family of the incident unless otherwise indicated in the individual’s plan.
• Notify the family of the findings of any investigation unless otherwise indicated in the individual’s plan.
• Maintain an investigation file within the agency.
• Create an incident management process which:
— Designates an individual with overall responsibility for incident management.
— Considers possible immediate and long-term effects to the individual resulting from an incident or multiple incidents.
— Uses trend analyses to identify systemic issues.
— Analyzes and shares information with relevant staff, including direct care staff.
— Periodically assesses the effectiveness of the incident management process.
— Monitors quality and responsiveness of all ancillary services (such as health, therapies, etc.) and acts to change vendors or subcontractors, or assists the individual to file available grievances or appeals procedures to secure appropriate services.
COUNTIES ARE TO:
• Promote the health, safety, rights and dignity of individuals receiving services.
• Develop county policies and procedures necessary to implement this bulletin.
• Have an administrative structure sufficient to meet mandates of this bulletin:
— Designate an individual with overall responsibility for incident management.
— Train staff in incident management procedures.
— Assure that supports coordinators have proper orientation and training to respond to, document and prevent incidents.
— Support providers with appropriate training and resources to meet the mandates of the bulletin.
• Provide ongoing training to individuals, families, guardians, and advocates regarding their rights, roles and responsibilities that are outlined in this bulletin.
• Provide training to individuals and families on the recognition of abuse and neglect.
• Have the Incident Management Processes in this bulletin referenced in county/provider contracts.
• Maintain an investigation file within the county.
• Create an incident management process which:
— Assures accuracy of incident reports.
— Reviews and closes all provider generated incidents.
— Reviews and analyzes data.
— Identifies and implements individual and systemic changes based on data analysis.
— Analyzes and shares information with relevant staff.
— Regularly reviews trend and occurrence data compiled by providers.
— Assesses provider’s incident management and investigative processes.
— Assures provider compliance with plans of correction resulting from incidents and investigations.
• Conduct certified investigations.
• Analyze the quality of investigations.
• Respond to concerns from individuals/family about the reporting and investigation processes.
• In collaboration with the individual’s planning team, revise the individual’s plan as needed in response to issues identified through the incident management process.
• Comply with all applicable laws, regulations and policies.
• Coordinate with other agencies as necessary.
• In those instances where the county is the initial reporter of the incident, the county will assume the responsibility of the point person.
THE OFFICE OF MENTAL RETARDATION IS TO:
• Promote the health, safety, rights and dignity of individuals receiving services.
• Create an incident management review process which:
— Maintains the statewide data system.
— Analyzes data for statewide trends and issues.
— Identifies issues and initiates systemic changes and provides periodic feedback.
— Evaluates county and provider reports and analysis of trends.
• Monitor implementation of this bulletin.
• Support providers and counties with appropriate training to meet the mandate of the bulletin.
• Certify investigators.
• Provide support and technical assistance to counties to implement the incident reporting system.
• Conduct certified investigations.
• Analyze the quality of investigations.
• Respond to concerns from individuals/families about the reporting and investigation processes.
• Review and revise this bulletin as needed.
• Ensure compliance with all applicable laws, regulations and policies.
• Coordinate with other agencies as necessary.
Source
The provisions of this Appendix E adopted February 27, 2004, effective February 21, 2004, 34 Pa.B. 1234.
Cross References
This appendix cited in 55 Pa. Code § 6000.902 (relating to purpose).
APPENDIX F
RELATED LAWS, REGULATIONS AND POLICIES
The incident management and reporting detailed in this subchapter are related to a variety of laws, regulations and policies. The applicable licensing regulations (and facilities licensed under those regulations) include:
Related Laws:
• The Mental Health and Mental Retardation Act of 1966 (50 P.S. § § 4101—4704)
• Title XIX Social Security Act (42 U.S.C.A. § § 1396—1396v)
• 18 Pa.C.S. § 2713 (relating to the neglect of care-dependent person)
• The Child Protective Services Law (23 Pa.C.S. § § 6301—6385)
• The Older Adults Protective Services Act (35 P.S. § § 10225.101—10225.5102)
• Elder Care Payment Restitution Act (35 P.S. § § 10226.101—10226.107)
• Early Intervention Services System Act (11 P.S. § § 875.101—875.503)
• The Whistleblower Law (43 P.S. § § 1422—1428)
Title 55 of the Pennsylvania Code.
• Chapter 20—Relating to Licensure or Approval of Facilities and Agencies
• Chapter 2380—Relating to Adult Training Facilities
• Chapter 2390—Relating to Vocational Facilities
• Chapter 3490—Relating to Child Protective Services
• Chapter 3800—Relating to Child Residential and Day Treatment Facilities
• Chapter 5310—Relating to Community Residential Rehabilitation Services for the Mentally Ill
• Chapter 6400—Relating to Community Homes for Individuals with Mental Retardation
• Chapter 6500—Relating to Family Living Homes
• Chapter 6600—Relating to Intermediate Care Facilities for the Mentally Retarded
Title 6 of the Pennsylvania Code (Aging).
• Chapter 11—Relating to Older Adult Daily Living Centers
Related Policy Guidelines:
• Medical Assistance Bulletin—Revised Medical and Treatment Self-Directive Statement: Your Rights As a Patient In Pennsylvania: Making Decisions About Your Care and Treatment (effective June 19, 1998)
• Mental Retardation Bulletin 00-98-08—Procedures for Substitute Health Care Decision Making (effective November 30, 1998)
• Mental Retardation Bulletin 00-94-32—Assessments: Lifetime Medical History (effective December 6, 1994)
• Mental Retardation Bulletin 00-03-01—Passage of Act 171 relating to the Older Adults Protective Services Act (OAPSA)
ADDITIONAL REPORTING:
In addition to the reporting methodologies described in this statement of policy, the following is provided as a guide to assist in identifying additional reporting. This does not fully define, nor is it intended to substitute for, the applicable statutes and regulations.
Reportable incidents involving individuals who reside in facilities licensed as ICF/MRs (both state and privately-operated), are to be reported to the appropriate Regional Field Office of the Pennsylvania Department of Health, Division of Intermediate Care Facilities.
Reportable incidents that occur in facilities licensed by OMR, involving individuals whose support needs are not funded through the Commonwealth or county mental retardation systems, are to be reported to whomever funds the individual’s support and to the Commonwealth/Regional Office of Mental Retardation. This includes individuals from other states, individuals who are funded by agencies not part of the mental retardation system and individuals whose support needs are privately funded.
Neglect of care-dependent person (18 Pa.C.S. § 2713)
The neglect of care-dependent person 18 Pa.C.S. § 2713 covers any adult who, due to physical or cognitive disability or impairment, requires assistance to meet his needs for food, shelter, clothing, personal care or health care. 18 Pa.C.S. § 2713 extends to certain listed facilities and to home health services provided to care-dependent persons in their residence. The statute criminalizes intentional, knowing or reckless conduct by a caregiver which results in bodily injury or serious bodily injury to a care-dependent person by the failure to provide treatment, care, goods or services necessary to preserve the health, safety or welfare of a care-dependent person for whom the caregiver is responsible to provide care. A caregiver may also be prosecuted if he intentionally or knowingly uses a physical restraint, a chemical restraint or medication on a care-dependent person, or isolates that person, contrary to law or regulation, such that bodily or serious bodily injury results.
Anyone aware of possible violations of this may make a report to the appropriate law enforcement authorities. The reporting requirements of this bulletin are to be followed even if a report of a possible violation of this statute is made to law enforcement authorities. Copies of the statute were distributed via Mental Retardation Bulletin 00-95-25, issued December 26, 1995 and Mental Retardation Bulletin 00-97-06, issued August 29, 1997.
The Child Protective Services Law (23 Pa.C.S. § § 6301—6385)
The Child Protective Services Law (CPSL) establishes procedures for the reporting and investigation of suspected child abuse. Certain types of suspected child abuse must be reported to law enforcement officials for investigation of criminal offenses. Children under the age of 18 are covered by the act including those who receive supports and services from the mental retardation system. Providers covered within the scope of this bulletin are required to report suspected child abuse in accordance with the procedures established in the CPSL and the Protective services Regulations. The CPSL defines child abuse as any of the following when committed upon a child under 18 years of age by a parent, person responsible for a child’s welfare, an individual residing in the same home as a child or a paramour of a child’s parent.
• Any recent act or failure to act that causes non-accidental serious physical injury.
• Any act or failure to act that causes nonaccidental serious mental injury or sexual abuse or sexual exploitation.
• Any recent act or series of such acts or failures to act that creates an imminent risk of serious physical injury or sexual abuse or sexual exploitation.
• Serious physical neglect constituting prolonged or repeated lack of supervision or the failure to provide essentials of life including adequate medical care which endangers a child’s life or development or impairs the child’s functioning.
Reports of suspected abuse are received by the Department of Human Service’s (DHS) ChildLine and Abuse Registry (800) 932-0313, which is the central register for all investigated reports of abuse. Individuals who come into contact with children in the course of practicing theirprofession are required to report when they have reasonable cause to suspect on the basis of their medical, professional or other training or experience, that a child is an abused child. Every facility or agency is required by the CPSL to funnel reports to the director or a designee to be promptly reported to ChildLine. The reporting, investigation and documentation requirements of this statement of policy must also be followed when a report of suspected child abuse is made. It must be noted that the definition of abuse found in the CPSL differs greatly from the definition promulgated in this statement. Because of this difference it is possible that an allegation may be ‘‘unconfirmed’’ in terms of the CPSL but still substantiated with reference to these guidelines. Likewise, the scope of reports subject to investigation differs so it is important to be familiar with the requirements of the CPSL.
The Older Adults Protective Services Act (35 P.S. § § 10225.101— 10225.5102)
The Older Adults Protective Services Act (OAPSA) of 1987 was enacted to protect all Pennsylvanians age 60 and older. The OAPSA established a detailed system for reporting and investigating suspected abuse, neglect, exploitation, and abandonment for care-dependent individuals. Act 13 was signed into law in 1997 as an amendment to the OAPSA. Unlike the other provisions of OAPSA that applied only to adults age 60 and above, Act 13 applied to adults age 18 and above who were considered ‘‘care-dependent’’ individuals and to ‘‘care-dependent’’ individuals under age 18 if they resided in a facility serving individuals over 18. Employees or administrators of a covered entity reported suspected abuse incidents to the local Area Agency on Aging, where indicated, to the Pennsylvania Department of Aging and to local law enforcement pursuant to Chapter 7 of the OAPSA. These requirements existed in addition to the reporting procedures contained in this Bulletin. In 2002, the OAPSA was further amended by the Elder Care Payment Restitution Act.
The Elder Care Payment Restitution Act (35 P.S. § § 10226.101—10226.107)
The Elder Care Payment Restitution Act eliminated the requirements of Act 13 for which suspected abuse of individuals with mental retardation under the age of 60 was reported to the Area Agency on Aging and in some cases, to the Department of Aging. This act became effective February 9, 2003.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Public Law 104-191)
HIPAA and the applicable regulations at 45 CFR Parts 160 and 164 (Privacy Rule) established a set of National standards for the protection of personal health information. The Privacy Rule addresses the use and disclosure of individuals’ health information or ‘‘protected health information’’ by organizations subject to the Privacy Rule or ‘‘covered entities.’’ The Privacy Rule establishes standards for individuals’ rights to understand and control how their personal health information is used. The U. S. Department of Health and Human Services, Office of Civil Rights is responsible to implement and enforce the Privacy Rule.
REPORTING MATRIX
The following is provided as a guide to assist in identifying additional reporting. This does not fully define, nor is it intended to substitute for, the applicable statutes and regulations.
| Reportable Incident | Report
to
OMR | Report
to
County1 | Report to AAA2 If 60 or older
| Report to
ChildLine if
under 18
| PA Department of
Aging3 If 60 or
older
| DOH
| Local Law
Enforcement
| Acts
28/264
|
| Death | X | X | If suspicious | If suspicious | If suspicious | If ICF/MR | If suspicious | If the result of neglect |
Disease Reportable
to the Department of Health | X | X | | | | X | | |
| Emergency Closure | X | X | | | | If ICF/MR | | |
| Emergency Room Visit | X | X | | | | If ICF/MR | | |
| Fire | X | X | | | | If ICF/MR | | |
| Hospitalization | X | X | | | | If ICF/MR | | |
| Individual to Individual Abuse | X | X | | | | If ICF/MR | | |
| Injury requiring treatment beyond first aid | X | X | | | | If ICF/MR | | |
| Law Enforcement Activity | X | X | | | | If ICF/MR | | |
| Medication Error | X | X | | | | If ICF/MR | | |
| Missing Person | X | X | | | | If ICF/MR | If person is at risk | |
| Misuse of Funds | X | X | If exploitation | | | If ICF/MR | If it appears that a crime has occurred | |
| Neglect | X | X | X | X | If serious bodily injury or serious physical injury | If ICF/MR | If serious bodily injury or serious physical injury | If serious bodily injury |
| Physical Abuse | X | X | X | X | If serious bodily injury | If ICF/MR | If serious bodily injury or serious physical injury | |
| Psychiatric Hospitalization | X | X | | | | If ICF/MR | | |
| Psychological Abuse | X | X | X | X | | If ICF/MR | | |
| Restraint | X | X | | | | If ICF/MR | | If serious bodily injury |
| Rights Violation | X | X | | | | If ICF/MR | | |
| Sexual Abuse | X | X | X | X | X | If ICF/MR | X | |
| Suicide Attempt | X | X | | | | If ICF/MR | | |
| Verbal Abuse | X | X | X | | | If ICF/MR | |
|
1 If an individual is not funded by OMR or by County MR services a report should be made to the funding agent.
2 Allegations of abuse or neglect involving children under 18 who reside in a facility that primarily serves adults must be reported to Child Line.
3 Allegations of abuse or neglect involving children under 18 who reside in a facility that primarily serves adults must be reported to Child Line.
4 Reporting under Acts 28/26 is only mandated for Commonwealth employees.
Source
The provisions of this Appendix F adopted February 27, 2004, effective February 21, 2004, 34 Pa.B. 1234.
Cross References
This appendix cited in; and 55 Pa. Code § 6000.951 (relating to initial reporter).
APPENDIX G
VICTIM’S ASSISTANCE PROGRAMS
When individuals are abused, neglected, injured or victims of crimes, there are resources to assist them physically, emotionally, financially and legally. Organizations have been developed based on the need to support victims through the criminal justice system, recognizing that victim’s needs are oftentimes overlooked. Individuals with disabilities who fall victim to crimes, especially physical violence and sexual assaults, should be encouraged and assisted to access these resources. It is suggested that providers develop relationships with local entities and assist individuals in accessing such services when appropriate.
There are two main types of victim assistance programs: system and community-based organizations. System-based programs that generally operate out of a District Attorney’s office provide notification to victims/witnesses of court proceedings. Community based programs are designed to provide support and assistance to victims. Usually, the programs fall under the categories of:
• Rape Crisis/Sexual Assault programs providing services to victims and their family/supporters. Domestic Violence programs provide counseling and temporary housing to victims, as needed.
• Crime Victim Services provide supports and assistance to victims of crimes excluding sexual assaults and domestic violence.
There are domestic violence centers, rape crisis centers and victim assistance offices throughout the Commonwealth. In order to locate the most appropriate resource for individuals, you may contact the following statewide organizations. Additional information regarding local resources is available through these organizations:
PA Commission on Crime and Delinquency (PCCD)
(717) 787-2040
PA Coalition Against Rape (PCAR)
(800) 692-7445
(717) 728-9740
PA Coalition Against Domestic Violence (PCADV)
(800) 932-4632
Office of Victim Advocate (crime victim compensation)
(717) 783-7501
Pennsylvania Protection and Advocacy (PP&A)
(800) 692-7443
Source
The provisions of this Appendix G adopted February 27, 2004, effective February 21, 2004, 34 Pa.B. 1234.
Cross References
This appendix cited in 55 Pa. Code § 6000.921 (relating to categories of incidents).
APPENDIX H
ABBREVIATED INCIDENT REPORT
Medication Error
The data entry screen is to include the following information:
• DEMOGRAPHICS (pre-populated from HCSIS demographics)
Name of the individual for whom the Medication Error is being reported.
Individual’s Base Service Unit (BSU) number.rr1;sup
1 If the individual is not registered with a County MH/MR Program, the report is to list the county or state where the person is/was a resident.
1
• CATEGORIZATION
Secondary category of Medication Error.
Date and time when the incident was recognized/discovered.
• MEDICATION ERROR INCIDENT INFORMATION
Staff position of the person giving medication.
Name of medication(s).
Indication if the error occurred over multiple consecutive administrations.
The reason(s) why the Medication Error occurred.
The response(s) to the Medication Error.
The agency system response to prevent this type of error from occurring in the future.
Any additional comments.
Indication if another Incident Report was filed as a result of the Medication Error.
If another Incident Report was filed, the Incident ID number.
In addition to the required information, providers may choose to include optional information to further analyze their medication errors.
• OPTIONAL MEDICATION ERROR INFORMATION
The name or unique identifier of person making the Medication Error.
Indication if the person making the Medication Error was working longer than their regular work hours at the time of the Medication Error.
The length of time the staff person who made the Medication Error has been giving medications.
The number of medications supposed to be given to this person at the same time as the Medication Error was made including the medication when the Medication Error was made.
The number of medications this person receives on a daily basis.
The number of people that the staff person who made the Medication Error has to give medications to around the same time as the Medication Error occurred.
Source
The provisions of this Appendix H adopted February 27, 2004, effective February 21, 2004, 34 Pa.B. 1234.
Cross References
This appendix cited in 55 Pa. Code § 6000.923 (relating to incidents to be reported within 72 hours); and 55 Pa. Code § 6000.924 (relating to incident management contingency plan).
APPENDIX I
ABBREVIATED INCIDENT REPORT
Restraint
The data entry screen is to include the following information:
• DEMOGRAPHICS (prepopulated from HCSIS demographics)
Name of the individual for whom the Restraint was used.
Individual’s Base Service Unit (BSU) number.r1;sup
1 If the individual is not registered with a County MH/MR Program, the report is to list the county or state where the person is/was a resident.
1
• CATEGORIZATION
Secondary category of Restraint.
Date of the Restraint.
Time in Restraint.
Time out of Restraint.
• RESTRAINT INCIDENT INFORMATION
Restraint agent.
Antecedent to the Restraint.
Reason for the Restraint.
Indication if the Restraint was used on a planned or emergency basis.
Authorizing Staff.
Indication if Prone (face down) Restraint was used.
Indication if another Incident Report was filed as a result of the Restraint.
If another Incident Report was filed the Incident ID number.
Source
The provisions of this Appendix I adopted February 27, 2004, effective February 21, 2004, 34 Pa.B. 1234.
Cross References
This appendix cited in 55 Pa. Code § 6000.923 (relating to incidents to be reported within 72 hours).
APPENDIX J
INCIDENT MANAGEMENT CONTINGENCY PLAN
In the event that a provider or county or entity is unable to report a 24-hour incident through the Home and Community Services Information System (HCSIS), faxed contingency reporting is to be utilized.
Incidents that are reported via fax are to be recorded on a copy of the attached Incident Management Contingency Form. This reporting method will satisfy regulatory requirements to report an incident. In the event of a serious incident (such as abuse with injury, suspicious death), a provider should also call its OMR Regional Office and County MH/MR Program to alert OMR and the county of the incident.
Once complete, the Incident Management Contingency Form is to be faxed to the appropriate OMR Regional Office and to the County MH/MR Program. The form should have a fax cover sheet that identifies the fax as a reportable incident and states the reason that the report needed to be faxed. Faxing the Incident Management Contingency Form is a short-term solution for meeting regulatory requirements for reporting incidents; however, once access to HCSIS can be established, the incident must be entered into HCSIS.
CONTACT INFORMATION:
OMR Regional Office Fax Numbers:
• Northeast Region (570) 963-3177
• Southeast Region (215) 560-3043
• Central Region (717) 772-6483
• Western Region (412) 565-5479
OMR Regional Office Phone Numbers:
• Northeast Region (570) 963-4391
• Southeast Region (215) 560-2242
• Central Region (717) 772-6507
• Western Region (412) 565-5144
Source
The provisions of this Appendix J adopted February 27, 2004, effective February 21, 2004, 34 Pa.B. 1234.
Cross References
This appendix cited in 55 Pa. Code § 6000.924 (relating to incident management contingency plan).
APPENDIX K
STANDARDIZED INCIDENT REPORT
FIRST SECTION (completed within 24 hours)
The First Section is to include the following information:
• DEMOGRAPHICS (pre-populated from HCSIS demographics)
Name of the individual involved/affected by the incident.
Individual’s Base Service Unit (BSU) number.ak1;sup
1 If the individual is not registered with a County MH/MR Program, the report is to list the county or state where the person is/was a resident.
1
County of Registration.
Gender.
Individual’s date of birth.
MR Diagnosis.
Home address of the individual.
Living Arrangement of the individual.
Name and address of the reporting entity.
Location where the incident occurred.
Name of the point person.
• CATEGORIZATION
Date and time when the incident was recognized/discovered.
Primary and secondary category of the incident.
Determination if an investigation is required or desired.
Name of the Certified Investigator assigned, if the incident requires investigation.
• HEALTH AND SAFETY ASSURANCE
Description of the immediate and subsequent steps taken by the point person or other representatives of the provider to ensure the individual’s health, safety and response to the incident, including date, time and by whom those steps were taken.
• INCIDENT DESCRIPTION
Narrative description of the incident completed by staff or other person(s) who were present when the incident occurred or who discovered that an incident had occurred.ak2;sup
2 Providers may summarize the narrative description, but the written statements of the person(s) directly invilved are to be available for review, if needed.
2
FINAL SECTION (completed within 30 days)
The reporting entity will complete the Final Section of the incident report within 30 days from the date of the incident or of the date the provider learns of the incident (unless an extension has been made). The Final Section will retain all of the preceding information from the First Section and will add:
Name of the initial reporter.
Name of the individual’s supports coordinator (pre-populated).
Whether CPR was administered.
Weather the Heimlich was administered.
If 911 was called, the time, date and person who called.
If the incident involves an illness or injury, the name of the practitioner/facility by whom the individual was treated initially, the date and time of the initial contact with a health-care/medical practitioner, the nature/content of the initial treatment/evaluation, and the nature of, date of, time of, and practitioner involved in any subsequent treatments, evaluations.
In the event of a death, indication if the individual was in hospice care, had a diagnosis of terminal illness, if a ‘‘Do Not Resuscitate’’ order was in effect, if the coroner was contacted, if an autopsy has been or will be performed.
Identification of all persons to whom the incident notification has been (or will be) submitted (i.e., family, law enforcement agency), the date the notification has been made, and the person who has/will notify the necessary parties.
Update of incident description, as needed.
Specific description of any injury received by the individual.
Present status of the individual in reference to the incident.
Identification of other persons who may have witnessed or been directly involved in the incident.
Specific signs and symptoms of any illness (acute or chronic) which may be contributory to the incident.
Any relevant background information on the individual, including medical history and diagnoses.
Date on which the investigation began, if required.
Summary of the investigator’s findings and conclusions, if required.
If the incident involves an allegation of abuse or neglect, the conclusion reached on the basis of the investigation (i.e., the allegation is confirmed, not confirmed, inconclusive) and the status of the target.
Description of the steps taken by the provider in response to the conclusions reached as a result of the investigation.
If the incident involves an injury of unknown origin, confirmation of the cause (if one has been identified) and steps taken to prevent recurrence.
Description of any changes in the individual’s plan of support necessitated by or in response to the incident.
Verification by the provider that all necessary corrective actions have been identified.
If any corrective action cannot/has not been completed by the time the Final Section is submitted, the expected date of completion must be provided along with the identity of the person responsible for carrying the extended action through to completion.
If the nature of the incident requires contact with local law enforcement, the name and department/office of the person(s) contacted, the date of the contact, the name of the person who initiated the contact, and a description of any steps taken by law enforcement officials.
If the individual has been hospitalized, the date of admission, name of the hospital, the admitting diagnosis(es), indication if the admission was from the emergency room, what occurred during the hospitalization, change in voluntary/involuntary status, the date of discharge, the discharge diagnosis(es), an indication that the Hospital Discharge Instructions were provided, what changed after discharge, current status and any plans for subsequent medical follow-up.
If the individual is deceased, the Final Section is to be supplemented by a hard copy of the following:ak3;sup
3 Documents, which are not immediately available, must be forwarded to the appropriate parties (county and/or OMR Regional Office) as they become available. If, after attempting to acquire the document, it is determined to be unobtainable, the expecting party will be notified.
3
— Lifetime medical history.
— Copy of the Death Certificate.
— Autopsy Report, if one has been completed.
— Discharge Summary from the final hospitalization, if the individual died while hospitalized.
— Results of the most recent physical examination.
— Most recent Health and Medical assessments.
Name of the family member notified of the results of the investigation, if required.
The incident classification the provider believes is most appropriate.
The date and time the provider believes is most appropriate.
After final submission by the provider, the county and OMR will perform a management review and close the incident.
Source
The provisions of this Appendix K adopted February 27, 2004, effective February 21, 2004, 34 Pa.B. 1234.
Cross References
This appendix cited in 55 Pa. Code § 6000.961 (relating to standardized incident report).1 If the individual is not registered with a County MH/MR Program, the report is to list the county or state where the person is/was a resident.
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