KMA Model Health Care Protocol on Abuse, Neglect & Exploitation Child, Spouse/Partner, Adult & Elder

VI. MODEL POLICY & ASSESSMENT FORMS

The following model policy and assessment forms are provided:

• to facilitate, simplify, and standardize quality health care intervention for patients at risk of abuse, neglect or exploitation;
• to assist physicians to comply with standards, regulations and laws related to adult and child abuse, neglect and exploitation.

Model Policy

This is intended as a model policy for assistance with patients who have suffered from abuse. This does not constitute official KMA policy, but rather protocol based on Kentucky Revised Statutes and Administrative Regulations.

I. Policy Statement

The (Name of Facility, Agency, or Practice) recognizes the crimes of adult and child abuse, neglect and exploitation as public health problems. These patients will be provided with quality, comprehensive medical treatment including access to appropriate protection and support services.

State laws mandate and this policy requires all known or suspected incidentsof child and adult (including spouse/partner) abuse, neglect, and exploitation to be reported to the local Department for Community Based Services (DCBS), and to other authorities as is appropriate. All legal requests for access to the facility or medical records from investigative authorities and the court will be honored in a timely manner.

Orientation on these topics and this policy should be provided for personnel.Compliance with policy and protocol will be monitored and enforced. Policy will be reviewed annually.

(Name of Facility, Agency, or Practice) will provide a safe health care setting and workplace to all patients, visitors, and employees. Special assistance will be made available, as is possible, for personnel who may be involved in situations related to adult or child maltreatment.

ALLservices and practices shall be administered without bias or prejudice of any form.

II. Definitions -- Target Population/Types of Maltreatment

Adults and children (including newborns & missing children) who may be victims of abuse, neglect, and exploitation.

III. Universal Screening -- Identification

Patients will be screened to assess for current maltreatment or a history of possible abuse, neglect or exploitation. If maltreatment is identified by the patient, or is suspected as the possible etiology of the injury or condition, detailed assessment and medical treatment will be conducted in a safe, private location (if possible).

IV. Treatment -- Intervention

Medical examination and treatment in these cases should include: comprehensive assessment; accurate documentation of any injuries and/or conditions (i.e., records, photographs); collection and preservation of evidence; diagnosis and treatment of any sexually transmitted infections (sexual abuse/assault); hospital admission ( if indicated); report to DCBS for the offer and/or provision of protection and support services (if indicated). Patients should be provided informational resources, referrals to community services, and other specialty care (if indicated); access to medical records and expert medical testimony (if requested).

V. Multidisciplinary Treatment

Multidisciplinary treatment, from presentation to discharge, is encouraged in cases of adult and child maltreatment. In cases of child sexual abuse, investigations are encouraged (by statute) to be conducted by established multidisciplinary teams (i.e., DCBS law enforcement, prosecutors, mental health professionals, and doctors who conduct child sexual abuse exams.) KRS 431.600

A. Consent. Consent for evaluation and treatment should be obtained per standard policy. Informed consent should be a continuing process with explanations provided about procedures as is possible. Personnel should comply if a patient refuses or is currently unable to complete a portion of the evaluation or treatment. It may be possible to complete it later.

In cases of known or suspected child maltreatment, the law allows certain information to be gathered (i.e., photographs, X-rays, or other appropriate medical diagnostic procedures) as part of a medical evaluation or investigation of a report without the consent of the parent or custodian. KRS 620.050(5)

Physicians and Sexual Assault Nurse Examiners (SANE) should obtain specific consent for sexual abuse evaluations of minors,particularly if photographs are to be taken. A minor may consent to a sexual abuse/assault examination. Such consent is not subject to disaffirmance because of minority. Consent of the parents or guardians of the minor is not required for such an evaluation. Violation of KRS 216B.400 and related regulations could result in statutory penalty and possible civil liability. KRS 216B.400(4); 40 KAR 3:010(1)(d); KRS 216.990(3)

Photographic documentation of injuries/condition is encouraged and should be included in the medical record. The patient’s decision to allow (or not allow) photographs to be taken should be noted in the record. Patients should be advised of the value of photographic documentation.

It is the patient’s choice whether or not to have the support person with them at any time during the reatment and evidence collection process. Patient consent to have a support person or victim advocate present must be given prior to the introduction of that person in the process.

B. Emergency Services. Where a person has been determined to be in need of emergency care by any person with admitting authority, no such person shall be denied admission by reason only of his inability to pay for services to be rendered by the hospital. KRS 216B.400(1)

At a hospital which offers emergency services, a physician or Sexual Assault Nurse Examiner is to be on call 24 hours each day for the examinations of persons reported to any law enforcement agency to be victims of sexual offenses. The physician or Sexual Assault Nurse Examiner must, upon request of any peace officer or prosecuting attorney, and with the consent of the reported victim, examine the person for the gathering of physical evidence. Sexual Assault Examination Certificates will be completed on appropriate cases and patient provided the Patient Information Form (rape victim services, STD/pregnancy information, etc.). KRS 216B.400(2); 314.011

Social workers do not have the authority to remove children and place them in a safe environment without a court order. (Exception: in extreme cases a social worker can remove a child committed to the state.) Law enforcement officers can remove children and place them in a safe environment when the officer determines a child to be in imminent danger.

Medical personnel may not take children into protective custody, but physicians and hospital administrators have the right to hold a child who they feel is in imminent danger. If a child is in the hospital, or under the immediate care of a physician, and appears to be in imminent danger if returned to the persons having custody, the physician or hospital administrator may hold the child without a court order. A request must be made to the court for an emergency custody order at the earliest practicable time, not to exceed (72) hours. KRS 620.040(3)(b)

Adults. If there is a question about a patient’s decision-making ability (e.g., dysfunctional), contact the hospital Community Based Services or the local DCBS to assess if guardianship or other services are indicated. Personnel should follow the usual procedures for obtaining consent in extraordinary cases (e.g., severely injured or incoherent persons).

If an adult lacks the capacity to consent to or refuse services, and is in a life-threatening situation, court-ordered emergency protective services may be indicated. Personnel will promptly notify and cooperate with DCBS staff (i.e., provide pertinent information, medical records, and testimony of the adult’s attending physician/specialist) to obtain a court order for medical treatment and related protective services.

C. High Risk Circumstances. In high risk circumstances, security and/or local law enforcement should be notified promptly to ensure the safety of the patient, any children, family members, medical personnel and others. If necessary, visitation with the patient should be restricted or monitored. A safety plan should be developed in cooperation with the patient and local protective services workers (e.g., DCBS, spouse abuse center).

If a protection or other court order (i.e., warrant) is indicated, local law enforcement and/or protective service workers should be contacted to assist the patient. If an order/warrant is issued or exists, the terms of such orders should be honored. Officers should be notified if assistance related to compliance with court orders is indicated.

VI. Documentation

All relevant historical and assessment information should be recorded on the chart (using the color-coded forms). The patient’s own words should be quoted whenever possible. A precise description of any current and healing injuries/conditions should be recorded as narrative and cross-referenced on charts (e.g., Body Injury Map, Skin Assessment) and on photographs, which become part of the medical record.

Patients should be advised of the importance of photographs. Personnel should follow established protocol for photographing patients. The patient’s decision to allow (or not to allow) photographic documentation should be noted in the record.

Documentation of any report made to DCBS, the Coroner, County/Commonwealth’s Attorney, or other authorities must be recorded in the record. Appropriate crime victim compensation forms should be completed (e.g., Sexual Assault Certification Form, Crime Victims Compensation Board).

VII. Reporting, Records, and Release of Information and Evidence

A. Reporting. An oral or written report of known or suspected child or adult (including spouse) abuse, neglect or exploitation must be made immediately to DCBS. As is appropriate, explanation of the role and services of DCBS should be made to the patient. No personnel (e.g., supervisors, etc.) may interfere with the making of a report to DCBS. Documentation of the report must be in the medical record. Statutes provide immunity from civil and criminal liability to persons reporting in good faith. Statutes also set forth penalties for failure to report. KRS Chapters 209; 620. Violation of state laws could result in sanctions (disciplinary, criminal, civil).

In cases of adult and child abuse reporting is required by law. In cases where there is reasonable cause to believe that an adult has suffered abuse, neglect or exploitation reports shall be made to the Cabinet for Health and Family Services. KRS 209.030. In cases where there is reasonable cause to believe that a child is abused, neglected or dependent, reports shall be made to the CHFS, law enforcement or the Commonwealth’s or county attorney. KRS 620.030

In the event of the death of the patient, or receipt of the body of an adult or child whose death may be related to maltreatment (known or suspected), personnel must report this information to the local Department for Community Based Services, law enforcement agency, Coroner and County or Commonwealth’s Attorney.

Patients in alcohol and drug abuse programs have special protections from certain disclosures. These protections, however, do not relieve a person or entity from the duty to report known or suspected child or adult abuse, neglect or exploitation. Appropriate personnel should comply with state reporting requirements for child abuse consistent with federal provisions; and adult maltreatment consistent with the procedures set forth in the opinion of the Legal Action Center (1988): encourage self-reporting; sign an informational release; or, absent these, make a report without revealing the patient (victim or perpetrator) is receiving alcohol/drug treatment services.

B. Records Personnel must allow any representative of DCBS access to the facility (licensed by Cabinet for Health and Family Services) at any reasonable time as part of mandated investigative responsibilities. Investigative access also includes: mental/physical health records of the alleged victim that are in the possession of any individual, hospital, or other facility.

Other authorities with investigative access to health care facilities/medical records: law enforcement agencies, Office of the Attorney General; Medicaid Fraud and Abuse Control Unit (OAG); Long Term Care Ombudsman; and US Department of Health and Human Services. Upon presentation of legal documentation to the custodian of the records, certified copies of medical records will be made available to investigative authorities or the court.

Patients should be advised they have access to copies of their medical records to assist them in any legal proceeding or victim compensation claim and about the proper use of the records.

C. Release of Information and Evidence. Personnel should assure the patient’s privacy and confidentiality will be maintained while services are being performed and coordinated with DCBS and other appropriate agencies. All information obtained by DCBS staff (or designated representative) as a result of an investigation of adult or child maltreatment is confidential. Information will not be divulged unless it is with appropriate professionals (e.g., medical, psychological, Community Based Services, law enforcement, etc.) who have a legitimate interest in the case, or by court order.

Confidential information may only be released with: patient consent; subpoena or court order; or documentation from authorities conducting investigations. Perpetrators, the media and others who do not have a legitimate interest in the case may attempt to secure information on the patient (whereabouts, health status, etc.). Information should not be divulged, especially by telephone, without specific authorization as cited above.

Discussion of case findings between personnel and others who do not have a legitimate interest in the cases is strongly discouraged.

D. Evidence. Physical evidence of adult and child maltreatment, not part of the medical record, (e.g., weapons, objects used as weapons, objects removed from the patient, specimens, clothing, etc.) should be collected and preserved consistent with protocol. These items may be released to law enforcement in the course of an investigation without the consent of the patient. (Note exception in alleged sex offense cases, which follows.) Personnel should retain for the record a receipt signed by the investigator which describes the items released.

In sexual abuse/assault cases, obtain written consent from the patient or an authorized third party (e.g., parent, guardian) on behalf of the patient, prior to releasing evidence collected as part of the sexual assault examination. If the patient does not authorize the release, she or he should be advised: 1) the release of evidence is not a commitment to prosecute; 2) the evidence will be stored properly for a designated time period during which the patient may reconsider the decision. If a court orders the release of the evidence as part of an investigation or prosecution, without the patient’s consent (rare), the court’s order must be honored.

VIII. Referrals/Discharge

It is imperative to provide the patient: 1) opportunity for safety planning; and 2) information about legal remedies and community services prior to leaving or discharge. If no safe place is available for victimized adult or child, hospitalization could be considered, if appropriate. DCBS should be notified of the planned discharge to assist the patient with follow-up services, if indicated. Provide patients with all relevant written materials describing identified problem areas, legal rights/remedies, community resources, and available medical services. Schedule a follow-up appointment, if possible.

IX. Personnel Issues

A. Education and Training. (Name of Facility, Agency, or Practice) shall facilitate orientation and in-service training on these topics and this policy for personnel. Training will comply with standards set forth by statute and relevant licensure boards.

(Name of Facility, Agency, or Practice) will provide a safe health care setting and workplace to all patients, visitors, and employees. Special assistance will be made available, as is possible, for personnel who may be involved in situations related to adult or child maltreatment.

ALL services and practices shall be administered without bias or prejudice of any form. Complaints regarding these matters should be promptly brought to the attention of supervisory staff for appropriate intervention or resolution. Compliance with policy and protocol will be monitored and enforced.

B. Liability. All employees will receive and sign for a copy of this policy. Personnel who would most likely encounter patients who may have been abused, neglected or exploited will additionally receive a copy of the established protocol for the handling of these cases. For clarification of questions related to these matters, refer to: supervisory staff, policy/protocol, training materials.

In cases of adult or child maltreatment, all personnel, and especially supervisory personnel, must follow established policy and protocol. Personnel who fail to do so increase the risk of potential liability (disciplinary, civil, criminal) for themselves and for (Name of Facility, Agency, or Practice).

C. Employee Assistance. Personnel who may be personally (directly/indirectly) involved in situations related to matters addressed in this policy will be eligible for assistance. These situations should be brought to the attention of supervisory staff.

Protection of victims is paramount. Supervisory personnel should comply with mandatory reporting laws and facilitate discussions with DCBS about available protective services. Confidentiality will be maintained as is legally appropriate. Supervisory personnel should discuss: safety planning for victims and service options (victims and perpetrators).

Requests for temporary leave (court appearances, participation in counseling programs, etc.) and extended absences from work (shelter stays, participation in substance abuse treatment programs, etc.), will be handled on individual basis.

Protection and other court orders must be honored. Compliance with terms and conditions established by (Name of Facility, Agency, or Practice), and/or the court, must be carefully monitored. Failure to comply with these terms or conditions will be documented and appropriate action taken immediately. These provisions serve to: 1) assist employees and their family members; and 2) to reduce the risk of liability for personnel and the (Name of Facility, Agency, or Practice).

Approved By: _______________________________________ Date: _____________________

Approved By: _______________________________________ Date: _____________________

Approved By: _______________________________________ Date: _____________________

Model documentation Forms

To assist physicians to thoroughly assess and document cases of known or suspected child or adult maltreatment, model forms appear as follows: 1) Interviewing the Family/Caretaker; 2) Interviewing and History Taking for an Adult; 3) Interviewing and History Taking for a Child; and 4) Assessment and Documentation Checklist: Adult/Child Sexual Abuse.

These assessment forms should be readily available to all medical and Community Based Services personnel, and may be photocopied for distribution and use. It is recommended these copies be on color-coded sheets or marked for easy recognition.

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