340:5-7-6. Long-Term Care Investigation elements
INSTRUCTIONS TO STAFF 340:5-7-6
1. The pre-investigation case review includes reading the case, making notes, reviewing any supporting documentation, contacting the reporter or other collateral to clarify information, and planning and scheduling the trip. Equipment, such as a camera, tape recorder, pens, pencils, and paper are checked and organized.
2. The investigation includes:
(1) Unannounced facility visit. The social service inspector (SSI) makes an unannounced, onsite visit to the facility. Facility visits are always unannounced. No calls are made to the facility and no one, including the caller, is told of the date and time of the visit.
(A) Entrance interview. Upon entering the facility, the SSI finds the administrator or staff in charge and introduces himself or herself and states the purpose for the visit. The SSI requests to see client and the client's records. The SSI establishes a work area at the facility.
(B) Client interview. The SSI introduces himself or herself and states the purpose for visit. He or she ensures that staff and family leave the room, conducts the interview, and determines client capacity.
(C) Facility records review. The SSI reviews the resident's chart and all related records, such as bathing sheets, food intake records, weight charts, incident reports, and trust accounts. He or she requests copies of pertinent records. The SSI with facility administrative staff reviews any problems with records, such as shorthand, difficult to read writing, missing records or documentation, and waits for the records to be found.
(D) Exit interview.
(i) The SSI tells facility administrative staff the current status of the complaint. He or she asks if staff has questions. The SSI may discuss problems identified during investigation, such as records, nursing, or failure to report. He or she informs facility staff of the procedure for completion of case and that they will receive a letter that includes the final disposition, whether substantiated, unsubstantiated, or inconclusive, other problems, and if other state agencies will be contacted.
(ii) The SSI does not make a substantiation decision at this time or discuss the findings with facility administration. He or she may educate administrative staff on issues identified during investigation. The SSI may request a plan of correction from administrative staff at this time, and offer in-service education for staff.
(2) Collateral interviews. Collateral interviews may be formal or informal and may occur at any time during the investigation. Collateral interviews include taking written statements. The SSI may provide information on laws or professional standards to assist staff in future work. Collateral interviews include an interview of the alleged perpetrator. Collateral interviews may include family members, other residents, nursing facility staff, physicians, other agency staff, law enforcement, and others.
(3) When involuntary services are needed to resolve the issue or assist the resident, a new referral for Community APS is entered into the APS Computer System.
(4) Photographs. Photographs including those taken of client's body, furniture, room and any other relevant facility feature, such as laundry carts or the kitchen may be taken at any time during the visit.
(5) Offsite work.
(A) Off-site record review. An in depth study of client records may be conducted off-site. The SSI requests any missing documentation. He or she may go to other facilities, such as hospitals, social service agencies, or law enforcement to obtain records. The SSI makes notes of pertinent documentation and collates records. He or she reviews applicable federal and state laws and regulation and professional practice guidelines.
(B) Off-site interviews. The SSI completes any collateral interviews. These are often done on the phone but the SSI may travel to meet collaterals for an in-person interview. He or she may request written statements and may consult with other agencies and law enforcement.
(6) Writing the report. The SSI organizes all of information developed during the investigation into a readable narrative within the program guidelines.
(7) Writing letters. Letters required after each investigation include letters to the next of kin and the facility administrator. Some cases may require letters to agencies, such as Oklahoma Human Services (OKDHS), Oklahoma Health Department, Ombudsman, Attorney General, Veterans Administration, or the Oklahoma Health Care Authority; boards, such as the Board of Nursing, Board of Examiners for Nursing Home Administrators, or Board of Medical Licensure; law enforcement; district attorneys; and others. Sample letters are provided to SSIs.
3. Review case with the program manager. At any time during the investigation but usually when the investigation is complete the SSI and program manager discuss:
(A) case issues;
(B) any problems encountered during the investigation;
(C) expected or unexpected delays in completion; and
(D) the substantiation decision.
4. Legal work. The SSI may be required to testify in depositions, agency or board proceedings, or in court. He or she may consult with OKDHS Legal Services attorneys as necessary.
5. Facility staff education. The SSI may educate staff on maltreatment and related issues, such as reporting maltreatment per Title 43A of the Oklahoma Statutes, to correct deficient work practice found during investigations and to prevent future occurrences of abuse. This is normally done one-on-one with staff. When the program manager approves, the SSI may do a facility educational in-service. The SSI does not agree to conduct an in-service training without consulting the program manager.