MUI Training Incidents adversely affecting health and safety. OAC 5123:

Objectives: Provide new and/or current staff/providers with an awareness of the importance incident reporting Create awareness about abuse and neglect so staff can identify and report information Educate staff on types of Unusual Incidents and MUI’s Educate staff/providers on the procedures and process of reporting incidents Educate staff/providers of roles and responsibilities of providers, support administrators, and investigative agent

The Rule: Establishes the requirements for managing incidents adversely affecting health or safety. Implements a continuous quality improvement process in order to prevent or reduce the risk of harm to individuals.

The Rule: The Purpose is to establish a system to: Report Investigate Review Remedy Analyze

An Unusual incident (UI) is: An event or occurrence involving an eligible individual that is not consistent with routine operations, policies and procedures, or the care or individual service plan of the individual, but is not an MUI. Unusual incidents directly relate to and are written about the individual receiving services that the incident happens to. Reports are about the victim, not the perpetrator

UI’s include but are not limited to: Minor Injuries Behavioral Episode Self-Medication Errors A-typical Behavior

Minor Injuries lacerations, scrapes, contusions or discolorations of known origin, minor burns, rash, minor recreational/work related injuries, falls; peer- to-peer incidents that are not MUIs; overnight relocation of an individual due to fire, natural disaster, or mechanical failure; any injury to an individual that is not an MUI.

Behavioral episode a physical or verbal outburst of an eligible individual that does not require physical intervention.

Self-medication errors an individual who administers their own medication (as outlined in their ISP) fails to administer the medication as prescribed (with no adverse effects).

Atypical behavior an occurrence where an eligible individual displays behavior that is unusual or displays a typical behavior increasingly which causes concern for health and safety.

A Major Unusual Incident (MUI) is: The alleged, suspected or actual occurrence of an incident when there is reason to believe the health or safety of an individual may be adversely affected. Or when an individual may be placed at a reasonable risk of harm. If such individual is receiving services through the DCBDD service system or will be receiving such services as a result of the incident. Major Unusual incidents directly relate to and are written about the individual receiving services that the incident happens to. Reports are about the victim, not the perpetrator

MUI’s include: Abuse Attempted suicide Death Exploitation Failure to report Known injury Law enforcement Medical emergency Misappropriation

MUI’s include: Missing individual Neglect Peer-to-Peer acts Prohibited sexual relations Rights code violation Unapproved behavior support Unknown injury Unscheduled hospitalization

PROTOCOL MUI’s Require 4 hour notification to DCBDD Require immediate Notification to Law Enforcement or Children Services in cases of suspected child abuse (up to age 21 for DCBDD Eligible individuals). Require immediate notification to Law Enforcement for criminal cases.

Failure to report: When a person has reason to believe that an individual has suffered or faces substantial risk of suffering from any wound, injury, disability, or condition of such a nature as to indicate abuse or neglect. Including misappropriation.

Failure to report: And that person does not immediately report the incident to: Law enforcement Children Services The DCBDD The Omission of the reporting is itself the MUI and must be reported immediately.

Abuse: Physical: use of physical force That can be expected to or does result in physical or serious physical harm. Including but not limited to: Hitting Slapping Pushing Throwing objects at an individual

Abuse: Sexual Abuse: Unlawful sexual conduct or sexual contact Verbal Abuse: Purposefully using words or gestures to threaten, coerce, intimidate, harass, or humiliate an individual

Misappropriation: Depriving, defrauding, or otherwise obtaining the real or personal property of an individual by any means prohibited by the Ohio Revised Code. It is a felony to steal even one penny!

Exploitation: The unlawful or improper act of using an individual’s resources for monetary or personal benefit, profit, or gain.

Neglect: When there is a duty to do so, failing to provide an individual with: Treatment Care Goods Supervision Services necessary to maintain the health or safety of the individual.

Neglect: Consideration must be given to whether there is reasonable risk to health and safety. Neglect includes patient endangerment which means an MR/DD caretaker has created a substantial risk to the health or safety of an individual.

Peer to Peer Acts: Act committed by one individual against another when there is: Physical abuse with intent to harm Verbal abuse with intent to intimidate, harass, or humiliate Any Sexual abuse Any Exploitation Intentional misappropriation of property of significant value – determined by ODMRDD to be about $10.00

Prohibited Sexual Relations: An MR/DD employee engaging in consensual sexual conduct or having consensual sexual contact with an individual who is not the employee’s spouse, and for whom the MR/DD employee was employed or under contract to provide care at the time of the incident and includes persons in the employee’s supervisory chain of command.

Rights Code Violation: Any violation of the rights enumerated in section of the Revised Code that creates a reasonable risk of harm to the health or safety of an individual.

NON PROTOCOL MUI Required to report the same day Required to implement immediate plan of correction to ensure health and safety.

Attempted Suicide & Death: Attempted Suicide: A physical attempt by an individual that results in emergency room treatment, in- patient observation, or hospital admission. Death: The death of an individual

Injury from a known cause: Is not considered as possible abuse or neglect Requires immobilization Requires castingRequires 5+ sutures or equivalent Is a 2 nd or 3 rd degree burn Includes dental injuries Any injury that prohibits the individual from participating in routine daily tasks for more that 2 consecutive days.

Law Enforcement: Any incident that results in the individual being charged, incarcerated, or arrested.

Medical Emergency: An incident where emergency medical intervention is required to save an individual’s life: Heimlich maneuver CPR IV fluid for dehydration

Missing Individual: An incident that is not considered neglect and the individual cannot be located for a period of time longer than specified in the Individual Service Plan (ISP) And the individual cannot be located after actions specified in the ISP And the individual cannot be located in a search of the immediate surrounding area Or the circumstances indicate that the individual may be in immediate jeopardy Or Law enforcement has been called to assist in the search

Unapproved Behavior Support: The use of any aversive strategy or intervention implemented without approval by the human rights committee or behavior support committee or without informed consent.

Unknown Injury: An injury of an unknown cause that is not considered possible abuse or neglect and that requires treatment that only a physician, physician’s assistant, or nurse practitioner can provide.

Unscheduled Hospitalization: Any hospital admission that is not that is not scheduled unless the hospital admission is due to a condition that is specified in the ISP or nursing care plan indicating the specific symptoms and criteria that require hospitalization.

(D)(1) Any Person with MRDD Not Served Report possible Abuse including Misappropriation or Neglect Report possible Abuse including Misappropriation or Neglect To local law enforcement and the county board To local law enforcement and the county board OR OR Public Children’s Service Agency and county board Public Children’s Service Agency and county board Entry page on ITS Entry page on ITS

Reporting MUI’s on Person served Abuse, Neglect, Exploitation, Misappropriation, Death, Prohibited Sexual Relations, and Failure to Report Regardless of where the incident occurred Follow all rule requirements Remaining categories (All other MUI’s) when: Incident occurs in program operated by the county board OR When the individual is being served by a licensed or certified provider Follow all requirements

(D)(3) Upon Identification or Notification of MUI, Provider or County Board Shall: Take immediate actions to protect all at risk individuals which shall include: Immediate or ongoing medical attention as appropriate Remove employee from direct contact until determined unnecessary Other measures as necessary The Department shall resolve any disagreements

(E) Alleged Criminal Acts Immediate reporting to law enforcement Allegations of Abuse including Misappropriation and Neglect which may constitute a criminal act The county board ensures notification has been made

(F) Abused or Neglected Children Allegations of Abuse or Neglect per Ohio Revised Code and Under the age of 21 Report to local public children’s agency The county board shall ensure reports have been made

(D)(5) Immediate to 4 Hour Reporting Provider or county board as a provider Using county board identified system for MUIs Report incidents or allegations of: Abuse Neglect Exploitation Misappropriation Suspicious or accidental death Media inquiries

(D)(10) County board shall have a system available 24-7 to receive and respond to reports. MUI notification numbers: During business hours (8am–4:30pm M-F) (740) ext. 303 After hours (4:30pm-8am), weekends, and holidays: (740)

(G)(1) Notifications Upon Awareness of an Incident To be made by provider or county board as a provider Made the same day Include immediate actions taken Guardian, advocate, or person identified SSA for individual Licensed or certified residential provider Staff or family in the home

(G)(2)-(4) Notifications or effort to notify shall be documented The county board ensure notifications have been made Do not notify the PPI, PPI’s spouse, or significant other Not needed if the report came from person to be notified or in the case of death where the family is already aware

(D)(4) County Board Upon Notification Shall: Ensure reasonable measures are appropriate Determine if additional measures are needed

(D)(6) Submit Written Incident Report by 3:00 p.m. the Next Working Day Agency providers, individual providers, and county boards as providers Department prescribed format: DCBDD IRF is included in training packet Fax #: (740) Attn: MUI Investigative Agent (Craig Hill) Find out appropriate SA fax number DCBDD IA and SA must have report by 3pm the next working day – do not use postal service or inter-office mail; if fax is not available, hand delivery is suggested

(G)(5) Notification to Providers When PPI Works for Multiple Providers The Department makes these Alleged crimes The other provider determines if steps are needed to ensure health and safety Notification of case disposition Providers, county boards, developmental centers to notify the Department if the PPI works elsewhere in the system

(K)(1) Written Procedure Implemented for Internal MUI Review County boards and agency providers Include responsibility for reasonable steps to prevent

(K)(2) Development of Preventive Measures Team including county board and provider Address causes and contributing factors Determine reasonable steps Plans of Prevention/Correction are due in their entirety, 21 days from the date the IDF was mailed In circumstances of few supports – implement what is reasonably possible.

(H) General Investigation Requirements

(H)(1) All MUIs require an investigation meeting the requirements in Appendix A or B Certified investigative agents shall conduct the investigations

(H)(2) The county board shall have at least one investigative agent. The county board may contract with a person or a government entity. Must be certified Must receive annual Department-approved training

(H)(5) Agency Provider may conduct HR investigations from which information except for interviews may be used The investigative agent shall conduct all interviews for MUIs unless Law enforcement or Children’s services is investigating May obtain assistance with interviewing an individual

(H)(6) Commence an investigation immediately but no later than 24 hours for: Abuse, Neglect, Exploitation, or Misappropriation Rights Code Suspicious or Accidental Death Prohibited Sexual Relations One determined by the county board

(H)(7) For other MUIs – Commence no later than 3 working days after identification or notification. Decision based upon: Initial information received Consistent with health and safety of at risk persons

(H)(10) When an agency provider conducts an internal review of an incident, (HR investigation) and an MUI has been filed The results of the review including statements and documents go to the county board within 14 calendar days of awareness of the incident

(H)(11) All MR/DD employees shall cooperate with any administrative investigation Providers and the county board shall respond to information within timeframes requested

(H)(12) The investigative agent submits the report of investigation for closure in ITS within 30 working days. Extensions may be granted by ODMR/DD based on established criteria.

(I)(1) Dept directed investigations The Department shall conduct the MUI investigation when the allegation is against: Superintendent of a county board or developmental center Executive Director or equivalent of a Counsel of Government Management employee who reports to the Superintendent or Executive Director An investigative agent An SSA An MUI contact for a county board A current member of a county board

(I)(1) Continued Known relationship with A-G when it may present a conflict of interest or the appearance of a conflict of interest County board employee who is alleged to be responsible for individual’s death, has committed sexual abuse, engaged in prohibited sexual activity, or committed physical abuse or neglect resulting in emergency room treatment or hospitalization.

(J)(1)(2) Those receiving written notice: Individual or individual’s guardian or advocate Licensed or certified provider and provider at the time of the incident SSA or person selected to coordinate services Not to family in case of death unless requested

(J)(3) Written summary not provided to PPI, PPI’s spouse, or significant other A reasonable attempt to notify the PPI of disposition shall be made no later than 5 working days following case closure

(J)(5) Findings may be disputed by: Individual or individual’s guardian, or individual’s advocate Provider Process: Submit letter of dispute and supporting documents to the County Board Superintendent within 15 days of receipt of the written summary. To Director if investigation was conducted by ODMR/DD

(J)(6) The superintendent shall consider information received and issue a determination in 30 calendar days Actions consistent with the determination shall be taken

(J)(7) The final finding of the county board may be disputed with the Director Findings and documentation contesting findings to the Director within 15 calendar days Decision in 30 calendar days

(K)(7) Closure Criteria Reasonable measures to ensure the health and safety of at risk individuals Thorough investigation per Appendix A and Appendix B Team collaboration on preventive measures to address causes and contributing factors Preventive measures have been implemented Additional action taken if a trend All rule requirements have been met

(K)(8) The county board notifies provider that case is closed within 5 working days.

(L)(1) MUI Analysis for Trends and Patterns Two Times Per Year County boards and agency providers July 31st for the first 6 months January 31st for the entire year

(L)(2) County Board’s Analysis and Follow-Up For county board operated programs, workshops, school, transportation For individual providers Sent to the Department by August 31st and February 28th

(L)(3) Agency Provider Analysis and Follow-Up For all programs in the county Sent by August 31st and February 28th to the county board Kept on file and made available upon request to the Department

(L)(4) The county board and Department shall review to ensure issues have been reasonably addressed to prevent reoccurrence.

(L)(5) County board ensures trends and patterns are included and addressed in the ISP.

(L)(8)(9)(10) Meet Twice a Year September for the first six months – March for the year Aggregate data sent to participants by the county board ten days prior to the meeting Record and distribute minutes and make available upon request The Department ensure follow-up actions are implemented

MUI Reporting, Investigation, Follow-up, and Closure DayDateActionProviderIAODMRDD Thurs1/11/07Becomes aware of possible physical abuse X Thurs1/11/07Takes immediate action to ensure health and safety X Thurs1/11/07Notifies law enforcement or CPS immediately X Thurs1/11/07Notifies DCBDD within 4 hours X Friday1/12/07Initiates investigation within 24 hours X Friday1/12/07Ensures notifications have been made X Friday1/12/07Sends required IRF form to DCBDD by 3pm. This is considered DCBDD’s discovery date X Mon1/15/07IA places the incident on ITS by 3pm X

MUI Reporting, Investigation, Follow-up, and Closure DayDateActionProviderIAODMRDD Tues1/16/07IA interviews victim within 3 working days X Thurs1/25/07Agency provider HR report sent to IA within 14 calendar days X Friday2/23/07Final report placed in ITS within 30 working days X Friday2/23/07Closure within 30 working days X Wed2/28/07ODMRDD reviews and closes case within 3 working days X Friday3/2/07IA sends out written summary within 5 calendar days after recommended for closure X Wed3/7/07IA provides disposition to PPI within 5 working days X

(M) Unusual Incident Requirements and Service Exceptions

(M)(1) Implement a Policy and Procedure Each agency provider and county board as a provider Identifies what is to be reported Anyone who becomes aware – report to designated person No later than 24 hours Appropriate actions to protect health and safety

(M)(2) Trained and Knowledgeable Staff Agency provider and county board as a provider must be trained on specific agency policy and procedure Individual provider – Initial and annual training on DCBDD policy and procedure

(M)(3)Unusual Incident Notification If the incident occurs at a county board operated or contracted site, the county board or contracted entity notifies: the licensed provider, staff, or family at the individual’s home Same day notification

(M)(4) Individual providers make reports to the person designated by the county board on the same day as discovery The county board designates a person to log the incidents – DCBDD designates the Support Administrator Rule does not specify report must be written; suggested best practice –write and maintain IRFs

(M)(5) Unusual Incidents are Reviewed at Least Monthly Who – agency providers and county board as a provider Support Administrator performing required tasks for individual providers are considered “county board as a provider” Appropriate preventive measures Trends and patterns identified and addressed

(M)(6) Unusual incident reports, documentation of trends and patterns, and corrective action made available to the county board and Department upon request.

(M)(7) Maintain a Log of Unusual Incidents Who – agency providers and county board as a provider Name of individual Brief description of incident Any injuries Time/date/location Preventive measures

(M)(8) County Board Review of Representative Sampling of Logs Monthly Provider logs, individual logs, and county board as a provider Ensure none are MUIs Ensure trends and patterns have been identified and addressed Provide to Department to review upon request

(M)(9) Department Review of Representative Sampling of Logs Monthly County board as a provider logs Submit to Department upon request Ensure none are MUIs Ensure trends and patterns have been identified and addressed

(M)(10) Trends and Patterns of Unusual Incidents Addressed in the ISP Who – agency provider and county board as a provider Rule does not specify SA, but it is logical to make the connection as it pertains to ISP development SA for individual provider Team - UI’s and MUI’s should be addressed by the team prior to and during ISP development