CMS SOM App. J, Tag W157

Guidance §483.420(d)(4)

The facility is required to ensure that clients residing in the facility are not subjected to physical,

verbal, sexual or psychological abuse or punishment.

Appropriate corrective action is required for findings of abuse, neglect or mistreatment by other

clients residing in the facility, staff of outside agencies, parents or any other person, and for

injuries to clients resulting from controllable environmental factors.

If the facility receives allegations of abuse, neglect, or mistreatment of a client during out of

facility visits with their family, they must report these allegations to the appropriate state

authority for investigation. The facility does not have to conduct an internal investigation

regarding the alleged violation.

Appropriate corrective action is defined as that action which is reasonably likely to prevent the

abuse, neglect, mistreatment or injury from recurring.

This regulation does not require staff termination as the only appropriate corrective action.

The corrective action imposed by the facility is commensurate with the violation.

When a facility is forced to re-hire a staff person, determined by the facility investigation to

have been responsible for abuse, neglect, or mistreatment, the facility continues to be

responsible for ensuring the health and safety of the clients, and ensures that those staff

members do not work directly with clients.