CMS SOM App. FC, Tag M0147

verbal, mental, sexual, and physical abuse, including injuries of unknown source, and

misappropriation of client property by anyone, including those furnishing services on

behalf of the CMHC, are reported immediately to the CMHC’s administrator by CMHC

employees, volunteers and contracted staff.

Interpretive Guidelines §485.910(d)(1)

For the purposes of this regulation and §485.910(d)(2), “immediately” means in the

absence of extenuating circumstances there should be no delay between staff awareness

of the occurrence and reporting to the Administrator as well as for the CMHC to

investigate all alleged violations.

Extenuating circumstances may include securing the situation and/or removing other

clients from harm. These would be the only reasons to delay in reporting or investigating.

For those adverse events identified as abuse, neglect, or mistreatment, facility

documentation should include, at a minimum, the following:

1. Date adverse event occurred;

2. Time adverse event occurred;

3. Time reported to Administrator;

4. The person(s) involved;

5. The location of the adverse event;

6. Any physical and/or emotional injuries to client; and

7. Description of the event including any witness statements.

The facility policies and procedures should detail who (either by name or title) will be

acting in the Administrator’s absence, if an adverse event occurs when the Administrator

is not on duty (vacation, holiday, etc.). The person(s) acting as Administrator in his/her

absence must have the authority to immediately investigate allegations and take whatever

corrective action is necessary to assure client health/safety.

In instances where the Administrator of the facility may be involved in an adverse event

of neglect, mistreatment, or verbal, mental, sexual and physical abuse, and

misappropriation of client property, the staff should follow the facility policy for

reporting to the appropriate person above the level of the Administrator. The facility

should have a written policy that directs the staff in these situations.