1. (a)

   1. (1) Pursuant to Arkansas Code § 12-12-1701 et seq. and Arkansas Code § 12-12-501 et seq. [repealed], the facility must develop and implement written policies and procedures to ensure incidents are prohibited, reported, investigated, and documented as required by this part and by law, including:

      1. (A) Alleged or suspected abuse or neglect of clients; and
      2. (B) Exploitation of clients or any misappropriation of client property.

   2. (2)

      1. (A) A facility is not required under this part to report death by natural causes.
      2. (B) However, nothing in this part negates, waives, or alters the reporting requirements of a facility under other rules or statutes.

   3. (3) Facility policies and procedures regarding reporting, as addressed in this part, must be:

      1. (A) Included in orientation training for all new personnel/staff/employees; and
      2. (B) Addressed at least annually during in-service training for all facility staff.

2. (b) Next-business-day reporting of incidents.

   1. (1) The following events shall be reported to the Office of Long-Term Care by facsimile transmission to telephone number 501-683-5306 of the completed Incident & Accident Intake Form (Form DMS-731) no later than 11:00 a.m. on the next business day following discovery by the facility:

      1. (A) Any alleged, suspected, or witnessed occurrences of abuse, including verbal statements or gestures, or neglect to clients;
      2. (B) Any alleged, suspected, or witnessed occurrence of misappropriation of client property or exploitation of a client; and
      3. (C) Any alleged, suspected, or witnessed occurrences of sexual abuse to clients by any individual.

   2. (2)

      1. (A) In addition to the requirement of a facsimile report by the next business day on Form DMS-731, the facility shall complete a Form DMS-742 in accordance with 20 CAR § 409-305(f).
      2. (B) Form DMS-731 and Form DMS-742 are found in the Appendix or on the office website at: http://www.medicaid.state.ar.us/InternetSolution/General/units/oltc/forms/forms.aspx

3. (c) Incidents or occurrences that require internal reporting only – Facsimile report or Form DMS-742 not required.

   1. (1) The following incidents or occurrences:

      1. (A) Shall require the facility to prepare an internal report only; and
      2. (B) Do not require a facsimile report or Form DMS-742 to be made to the office.
   2. (2) The internal report shall include all content specified in 20 CAR § 409-305(f), as applicable.

   3. (3) Facilities must maintain these incident report files in a manner that allows verification of compliance with this provision:

      1. (A)

4. (i) Incidents where a client attempts to cause physical injury to another client without resultant injury.

   1. (ii) The facility shall maintain written reports on these types of incidents to document patterns of behavior for subsequent actions;

      1. (B) All cases of reportable disease as required by the Department of Health; and

      2. (C) Loss of heating, air conditioning, or fire alarm system for a period of greater than two (2) hours.

         1. (d) Internal-only reporting procedure.

   2. (1)

      1. (A) Written reports of all incidents and accidents shall be completed within five (5) days after discovery.
      2. (B) The written incident and accident reports shall be comprised of all information specified in Form DMS-731 and Form DMS-742 as applicable.
      3. (C) All written reports will be reviewed, initialed, and dated by the facility program director or designee within five (5) days after discovery.
   3. (2) All reports involving accident or injury to clients will also be reviewed, initialed, and dated by the facility registered nurse within five (5) days of the review by the facility program director.

   4. (3) The care plan portion of the admission agreement shall be reviewed by the registered nurse and:

      1. (A) Shall be amended upon any change of a client’s condition or need for services; and
      2. (B) Copies of the amended versions of the care plan shall be attached to the written report of the incident or accident.
   5. (4) Reports of incidents specified in this subsection will be maintained in the facility only and are not required to be submitted to the office.
   6. (5) All written incident and accident reports shall be maintained on file in the facility for a period of three (3) years from the date of occurrence or report, whichever is later.
5. (e) Other reporting requirements. The facility’s program director or designee is also required to make any other reports as required by state and federal laws and regulations.

6. (f) Abuse investigation report.

   1. (1) The facility must ensure that all alleged or suspected incidents involving client abuse, exploitation, neglect, or misappropriations of client property are thoroughly investigated.

   2. (2) The facility’s investigation must:

      1. (A) Be in conformance with the process and documentation requirements specified on the Form DMS-742; and
      2. (B) Prevent the occurrence of further incidents while the investigation is in progress.
   3. (3) The results of all investigations must be reported to the facility’s program director or designated representative and to other officials in accordance with state law, including the office, within five (5) working days of the facility’s knowledge of the incident.
   4. (4) If the alleged violation is verified, appropriate corrective action must be taken.

   5. (5)

      1. (A) The DMS-742 shall be completed and mailed to the office by the end of the fifth working day following discovery of the incident by the facility.
      2. (B) The DMS-742 may be amended and resubmitted at any time circumstances require.

7. (g) Reporting suspected abuse or neglect.

   1. (1) The facility’s written policies and procedures shall include, at a minimum, requirements specified in this section.
   2. (2) The requirement that the facility’s program director or his or her designated agent immediately reports all cases of suspected abuse or neglect of clients of an adult day health care to the local law enforcement agency in which the facility is located as required by Arkansas Code § 12-12-1708(b)(1)(A) and as amended.
   3. (3) The requirement that the facility’s program director or his or her designated agent report suspected abuse or neglect to the office as specified in this part.
   4. (4) The requirement that all facility personnel/staff/employees who have reasonable cause to suspect that a client has been subjected to conditions or circumstances that have resulted in abuse or neglect are required to immediately notify the facility program director or his or her designated agent (this does not negate that all mandated reporters employed by or contracted with the facility shall report immediately to the local law enforcement agency in which the facility is located as required by Arkansas Code § 12-12-1708(b)(1)(A)).

   5. (5)

      1. (A) The requirement that, upon hiring, each facility employee:

         1. (i) Be given a copy of the abuse or neglect reporting and prevention policies and procedures; and
         2. (ii) Sign a statement that the policies and procedures have been received and read.
      2. (B) The statement shall be filed in the employee’s personnel file.
   6. (6) The requirement that all facility personnel receive annual, in-service training in identifying, reporting, and preventing suspected abuse or neglect, and that the facility develops and maintains policies and procedures for the prevention of abuse and neglect and accidents.

   7. (7)

      1. (A) When the office makes a finding that a facility employee or personnel of the facility committed an act of abuse, neglect, or misappropriation of client property against a client, the name of that employee or personnel shall be placed in the Employment Clearance Registry of the office.
      2. (B) If the employee or personnel against whom a finding is made is a CNA, the name of the CNA will be placed in the CNA Registry of the office.
      3. (C) Further, the office shall make report of its finding to the appropriate licensing or enforcement agencies.

Codification Notes: Code § 12-12-501 et seq. was repealed by Acts 2009, No. 749, § 2. "CNA" means certified nursing assistant.