CMS SOM App. L, Tag Q-0233

The patient has the right to –

(3) Be free from all forms of abuse or harassment.

Interpretive Guidelines: §416.50(f)(3)

An ASC must prohibit all forms of abuse, neglect (as a form of abuse), and harassment

from staff, other patients, or visitors. The ASC must have mechanisms/methods in place

ensure that patients are free from all forms of abuse, neglect, or harassment.

As discussed in the guidance for §416.50(d), abuse is the willful infliction of injury,

unreasonable confinement, intimidation, or punishment with resulting physical harm,

pain or mental anguish or mental illness and neglect is the failure to provide goods and

services necessary to avoid physical harm, mental anguish, or mental illness. The

Merriam Webster Dictionary defines “harassment” as creating an unpleasant or hostile

situation, especially by uninvited and unwelcome verbal or physical conduct.

The following components are suggested as necessary for effective protection from

abuse, neglect or harassment:

Prevent - Persons with a record of abuse or neglect should not be hired or retained as

employees. It is recommended that the ASC have a process in place to screen all

applicants for employment or privileges to practice in the ASC.

Identify - The ASC should create and maintain a proactive approach to identify events

and occurrences that may constitute or contribute to abuse and neglect.

Train - The ASC, during its orientation program, and through an on-going training

program, should provide all employees with information regarding patient abuse and

neglect, including who in the ASC is authorized to receive and handle allegations of

abuse and neglect.

Investigate - The ASC ensures, in a timely and thorough manner, an objective

investigation of all allegations of abuse, neglect, or mistreatment. This includes

investigation not only of grievances from patients or their representatives, for which the

grievance process prescribed in §416.50(d) must be used, but also allegations from any

other source.

Respond - The ASC should assure that any and all incidents of abuse, neglect, or

harassment are reported and analyzed, and the appropriate corrective, remedial or

disciplinary action occurs, in accordance with the applicable local, State, or Federal law.

Survey Procedures: §416.50(f)(3)

Examine the extent to which the ASC has a system in place to protect patients from

abuse, neglect, and harassment of all forms, whether from staff, other patients, visitors, or

other persons. In particular, determine the extent to which the ASC addresses the

following issues:

• Does the ASC have policies and procedures for investigating allegations of abuse

and neglect in addition to the required grievance process that applies to

allegations from patients or their representatives?

• Does the ASC use the same process as for grievances alleging abuse and neglect?

If not, what is the ASC’s policy and process, including the process for training

staff?

• Interview staff to determine if staff members know what to do if they witness

abuse and neglect.

• Ask the ASC if it has had any allegations of patient abuse or neglect from any

source during the past year? If it has, ask the ASC to provide the files and to

describe how the matter was handled.

• Review the records to see if the appropriate agencies were notified in accordance

with State and Federal laws regarding incidents of substantiated abuse and

neglect?