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KATIE ADULT DAY CENTER POLICIES AND PROCEDURES

SUBJECT: Maltreatment of Vulnerable Adults


Reference: Minnesota Statutes, chapter 245A.65 and 626.557
Document Number: 05-013.16
POLICY: It is the policy of this DHS licensed provider to protect the adults served
by this program who are vulnerable to maltreatment and to require the
reporting of suspected maltreatment of vulnerable adults.

PROCEDURE:
1. A staff member of this licensed service provider who has reason to believe that a
vulnerable adult is being or has been maltreated, or who has knowledge that a
vulnerable adult has sustained a physical injury which is not reasonably explained shall
immediately report the information to the common entry point, or to their
_________________ and __________________ [identify primary and secondary
person or position for internal reporting] for internal investigation and reporting as
indicated by results of the investigation.
Immediately means, as soon as possible, but no longer than 24 hours from the time
initial knowledge that the incident occurred has been received.
2. An external report can be made to the Minnesota Adult Abuse Reporting Center,
MAARC, at (844) 880-1574, or on line at: www.mn.gov/dhs/reportadultabuse , or an
internal report may be made to the Center Director or designee.
3. When an internal report is received, the Center Director and Nurse are responsible for
deciding if a report to the Common Entry Point is required. The secondary person shall
be involved when there is reason to believe that the primary person was involved in the
alleged or suspected maltreatment. The report must be forwarded within 24 hours. The
report to the Common Entry Point, MAARC, must be as soon as possible from the time
initial knowledge that the incident occurred has been received. An internal reporter will
be notified in writing within 2 days, by the Center Director whether or not the report
has been forwarded to the Common Entry Point. The notice must be given in a manner
that protects the confidentiality of a reporter. It shall inform the reporter that if not
satisfied with the action taken by the center on whether to report the incident to the
common entry point, they may still make an external report to the Common Entry Point.
It will also inform the reporter that are protected against retaliation by the center if
making a good faith report to the Common Entry Point.
4. What to report:
a. Definitions of maltreatment of vulnerable adults are contained in Minnesota
Statutes, section 626.5572. Current definitions are attached to this policy.

Katie Adult Day Center Policies and Procedures Manual 05-013.16


Verbal or physical aggression occurring between patients, residents, or clients
of a facility, or self-abusive behavior by these persons does not constitute
abuse unless the behavior causes serious harm.
b. An external or internal report should contain enough information to identify
the vulnerable adult, the caregiver, the nature and extent of the suspected
maltreatment, any evidence of previous maltreatment, the name and
address of the reporter, the time, date, and location of the incident, and any
other information that the reporter believes might be helpful in investigating
the suspected maltreatment.
5. The program must document completion of the internal review and provide
documentation of the review to the DHS upon the commissioner's request.
6. A corrective action plan is developed as necessary to protect the health and safety of
vulnerable adults when the center has reason to know that an internal or external
report of alleged or suspected maltreatment has been made. The review includes an
evaluation of whether related policies and procedures were adequate, whether there is
a need for additional staff training, whether the reported event is similar to past events
with the vulnerable adults or the services involved, and whether there is a need for
corrective action by the license holder to protect the health and safety of vulnerable
adults. Based on the results of this review, the center will develop, document, and
implement a corrective action plan within 30 days of notice of incident designed to
correct current lapses and prevent future lapses in performance by individuals or the
license holder, if any.
7. The program shall provide an orientation to the internal and external reporting
procedures to all persons receiving services. The orientation shall include the telephone
number for the Common Entry Point. A persons legal representative will be notified of
the orientation. The program shall provide this orientation for each new person within
24 hours of admission, or for persons who would benefit more from a later orientation;
the orientation may take place within 72 hours.
8. Staff training: Center staff will receive orientation and training related to the reporting
of maltreatment. (Online mandated reporter training from DHS may be used for general
training in addition to training on the Centers own policies and procedures:
http://www.dhs.state.mn.us/media/flash/Training%20modules%20on%20guidelines%2
0for%20mandated%20reporting/public9.htm .)
9. A copy of the internal and external reporting policies and procedures, will be posted in a
prominent location in the center, and is available upon request to mandated reporters,
persons receiving services, and the persons legal representatives.

Katie Adult Day Center Policies and Procedures Manual 05-013.16

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