Current through Register Vol. 35, No. 6, March 26, 2024
A.
Duty to report:
(1) All community-based
providers shall immediately report alleged crimes to law enforcement or call
for emergency medical services as appropriate to ensure the safety of
consumers.
(2) All community-based
service providers, their employees and volunteers shall immediately call the
department of health improvement (DHI) hotline at 1-800-445 -6242 to report
abuse, neglect, exploitation, suspicious injuries or any death and also to
report an environmentally hazardous condition which creates an immediate threat
to health or safety.
B.
Reporter requirement. All community-based service providers shall
ensure that the employee or volunteer with knowledge of the alleged abuse,
neglect, exploitation, suspicious injury, or death calls the division's hotline
to report the incident.
C.
Initial reports, form of report, immediate action and safety planning, evidence
preservation, required initial notifications:
(1)
Abuse, neglect, and exploitation,
suspicious injury or death reporting: Any person may report an
allegation of abuse, neglect, or exploitation, suspicious injury or a death by
calling the division's toll-free hotline number 1-800-445 -6242. Any consumer,
family member, or legal guardian may call the division's hotline to report an
allegation of abuse, neglect, or exploitation, suspicious injury or death
directly, or may report through the community-based service provider who, in
addition to calling the hotline, must also utilize the division's abuse,
neglect, and exploitation or report of death form. The abuse, neglect, and
exploitation or report of death form and instructions for its completion and
filing are available at the division's website,
http://dhi.health.state.nm.us, or
may be obtained from the department by calling the division's toll free hotline
number, 1-800-445 -6242.
(2)
Use of abuse, neglect, and exploitation or report of death form and
notification by community-based service providers: In addition to
calling the division's hotline as required in Paragraph (2) of Subsection A of
7.1.14.8 NMAC, the community-based service provider shall also report the
incident of abuse, neglect, exploitation, suspicious injury, or death utilizing
the division's abuse, neglect, and exploitation or report of death form
consistent with the requirements of the division's abuse, neglect, and
exploitation reporting guide. The community-based service provider shall ensure
all abuse, neglect, exploitation or death reports describing the alleged
incident are completed on the division's abuse, neglect, and exploitation or
report of death form and received by the division within 24 hours of the verbal
report. If the provider has internet access, the report form shall be submitted
via the division's website at
http://dhi.health.state.nm.us;
otherwise it may be submitted via fax to 1-800-584 -6057. The community-based
service provider shall ensure that the reporter with the most direct knowledge
of the incident participates in the preparation of the report form.
(3)
Limited provider
investigation: No investigation beyond that necessary in order to be
able to report the abuse, neglect, or exploitation and ensure the safety of
consumers is permitted until the division has completed its
investigation.
(4)
Immediate
action and safety planning: Upon discovery of any alleged incident of
abuse, neglect, or exploitation, the community-based service provider shall:
(a) develop and implement an immediate action
and safety plan for any potentially endangered consumers, if
applicable;
(b) be immediately
prepared to report that immediate action and safety plan verbally, and revise
the plan according to the division's direction, if necessary; and
(c) provide the accepted immediate action and
safety plan in writing on the immediate action and safety plan form within 24
hours of the verbal report. If the provider has internet access, the report
form shall be submitted via the division's website at
http://dhi.health.state.nm.us;
otherwise it may be submitted by faxing it to the division at 1-800-584
-6057.
(5)
Evidence preservation: The community-based service provider shall
preserve evidence related to an alleged incident of abuse, neglect, or
exploitation, including records, and do nothing to disturb the evidence. If
physical evidence must be removed or affected, the provider shall take
photographs or do whatever is reasonable to document the location and type of
evidence found which appears related to the incident.
(6)
Legal guardian or parental
notification: The responsible community-based service provider shall
ensure that the consumer's legal guardian or parent is notified of the alleged
incident of abuse, neglect and exploitation within 24 hours of notice of the
alleged incident unless the parent or legal guardian is suspected of committing
the alleged abuse, neglect, or exploitation, in which case the community-based
service provider shall leave notification to the division's investigative
representative.
(7)
Case
manager or consultant notification by community-based service providers:
The responsible community-based service provider shall notify the consumer's
case manager or consultant within 24 hours that an alleged incident involving
abuse, neglect, or exploitation has been reported to the division. Names of
other consumers and employees may be redacted before any documentation is
forwarded to a case manager or consultant.
(8)
Non-responsible reporter:
Providers who are reporting an incident in which they are not the responsible
community-based service provider shall notify the responsible community-based
service provider within 24 hours of an incident or allegation of an incident of
abuse, neglect, and exploitation.
D.
Incident policies: All
community-based service providers shall maintain policies and procedures which
describe the community-based service provider's immediate response, including
development of an immediate action and safety plan acceptable to the division
where appropriate, to all allegations of incidents involving abuse, neglect, or
exploitation, suspicious injury as required in Paragraph (2) of Subsection A of
7.1.14.8 NMAC.
E.
Retaliation: Any person, including but not limited to an employee,
volunteer, consultant, contractor, consumer, or their family members, guardian,
and another provider who, without false intent, reports an incident or makes an
allegation of abuse, neglect, or exploitation shall be free of any form of
retaliation such as termination of contract or employment, nor may they be
disciplined or discriminated against in any manner including, but not limited
to, demotion, shift change, pay cuts, reduction in hours, room change, service
reduction, or in any other manner without justifiable reason.
F.
Quality assurance/quality
improvement program for community-based service providers: The
community-based service provider shall establish and implement a quality
improvement program for reviewing alleged complaints and incidents of abuse,
neglect, or exploitation against them as a provider after the division's
investigation is complete. The incident management program shall include
written documentation of corrective actions taken. The community-based service
provider shall take all reasonable steps to prevent further incidents. The
community-based service provider shall provide the following internal
monitoring and facilitating quality improvement program:
(1) community-based service providers shall
have current abuse, neglect, and exploitation management policy and procedures
in place that comply with the department's requirements;
(2) community-based service providers
providing intellectual and developmental disabilities services must have a
designated incident management coordinator in place; and
(3) community-based service providers
providing intellectual and developmental disabilities services must have an
incident management committee to identify any deficiencies, trends, patterns,
or concerns as well as opportunities for quality improvement, address internal
and external incident reports for the purpose of examining internal root
causes, and to take action on identified issues.
