ATTACHMENT 12- LEXINGTON VAMC PATIENT ABUSE NEGLECT SEXUAL TRAUMA AND THREATS OF VIOLENCE POLICY.pdf

PATIENT ABUSE, NEGLECT, SEXUAL TRAUMA, AND THREATS OF VIOLENCE

MCP 122-09

Lexington VA Health Care System Lexington, KY 40502

Signatory Authority:

Rescinded Document:

122-09, Patient Abuse, Neglect, Sexual

Trauma and Threats of Violence, 04/29/2020

Gregory W. Goins, FACHE Director Effective Date:

Responsible Owner: November 30, 2020 Social Work

Recertification Date:

November 30, 2025

1. POLICY: To provide guidance to VA Health Care System staff regarding recognition and reporting of suspected patient abuse, neglect, exploitation, and violence.

2. JUSTIFICATION: Health care providers, employees, volunteers, and students must immediately report the following cases below. The exception is for Intimate Partner Violence, which was previously called Domestic Violence, which is excluded as mandatory reporting in Kentucky effective 2017 (see 3.c.).

a. Alleged victims of mental abuse. This includes humiliation, harassment, and threats of punishment or deprivation.

b. Alleged victims of physical abuse. This includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

c. Alleged survivors of sexual abuse. This includes sexual harassment, sexual coercion, and sexual assault.

d. Alleged victims of neglect where there is suspicion that the patient's basic needs are not being met. This includes withholding or inadequately providing food and hydration (without physician or surrogate approval), clothing, medical care, and responsible hygiene. This could mean putting the patient at risk in unsafe or unsupervised situations. Patients should also be reported if there is the possibility of significant self-neglect.

e. Alleged victims of exploitation. This includes misappropriation of the patient's funds and assets for another's advantage or benefit.

3. RESPONSIBILITIES:

a. Clinical Staff is responsible for routinely screening for suspected abuse, neglect, exploitation, domestic violence, and sexual trauma. If a patient indicates she or he is presently being abused, staff must assess for immediate safety needs and assist the victim (veteran and non-veterans) in developing a safety plan and making them aware

November 30, 2020 MCP 122-09 of appropriate community and VA resources

b. Service Chiefs, Service Line Managers, and other Program Managers are responsible for the overall implementation of this policy. This includes ensuring that their staff is trained on abuse, neglect, exploitation, domestic violence, and sexual assaulVrape as outlined in this policy.

c. The Chief of Social Work Service is responsible for working with Public Affairs to keep current Abuse Hotline numbers for the Kentucky Cabinet for Health and Family Services posted in areas of patient care. This includes prominent areas of the Lexington VA Health Care System campuses. The Chief of Social Work Service will coordinate with Public Affairs to have education and referral agency information available to all clinical staff and AODs for alleged victims of lnterpersonal Partner Violence.

d. The Chief of Social Work Service and Social Work supervisors will coordinate with appropriate administrative, non-clinical VA staff to document their report of alleged abuse, neglect or exploitation on VA Form 1'19 Report of Contact with the format in Attachment A.

4. PROCEDURES:

a. Reports of abuse, neglect, or exploitation

(1) Any person actively employed within the Lexington VA Health Care System who has REASON TO SUSPECT that a patient has been abused, neglected or exploited by someone outside of the VA, shall report to the Cabinet for Heath and Family Services. NOIE: Refer to SOP 122-04 for the procedures to be followed for suspected Abuse of Patients by any Lexington VA Health Care employee, volunteer, or consultanUcontractor.

(a) Any clinical staff member of the Lexington VA will complete the "lnitial Assessment for Adult (and Child) Protective Services Referral" progress note in the electronic health record (EHR). This will be done at the time they observe or hear evidence leading to suspected abuse, neglect or exploitation of the patient. VA clinical staff will also call the Cabinet for Health and Family Services to report and document that call on the above listed progress note.

(b) Non-clinical staff at the Lexington VA Health Care System campuses shall immediately contact their supervisorA/A liaison and together complete a VA Form 119 with the format identified in Attachment A. The Supervisor will assist the employee in reporting the incident to the Cabinet for Health and Family Services and document the contact referral number on VA Form 1 19, Report of Contact. lf the supervisor has questions, he/she can consult with a) Social Work Section during regular business hours, 8am-4pm or b) the Administrative Officer on Duty (AOD) after 4pm on regular business days or after hours, or c) for the Community Based Outpatient Clinic (CBOC), the Social Worker or in the Social Worker's absence, the AOD or other designated supervisory staff. The Social

November 30,2020 MCP 122-09

Worker or AOD will coordinate with file room Supervisor or designee to have VA Form 1 '19, Report of Contact scanned in the EHR. The Social Worker or AOD will enter the EHR note, referencing the report to AdulUChild Protective Services and that the administrative report was scanned into the EHR.

(e) Social Work Service is available for consultation during business hours but are not responsible for reporting for other VA staff who observed incidents leading to suspicion of abuse, neglect, or exploitation of patients.

b. ldentification and Reporting: The patient must be advised by the practitioner that he/she has the right to accept or refuse any aspect ofthe medical evaluation and treatment or forensic evidentiary examination. This may include examination for the presence of injuries sustained because of the assault, evidence of sexual assault, and collection of physical evidence to include photographs of injuries and further examination as provided for by state law. The practitioner must ensure the patient understands that refusal of the forensic examination for evidence of sexual assault is not a ground for denial or treatment for injuries, possible pregnancy, and sexually transmitted diseases if the patient wishes to obtain treatment. The practitioner must ensure the patient understands it is his/her choice if to report the assault and the patient can withdraw his/her consent at any time during an examination. As part of this discussion, the patient must be informed that he/she has the option to have forensic evidence collected anonymously during the examination and has the option to decide later if to cooperate with law enforcement. Refusal of any recommended treatment or procedure must be documented in the patients' health record and those treatments or procedures must not be provided.

c. Release of information

(1) lnformation regarding abuse, neglect and exploitation as described above can be released to the appropriate Kentucky State agencies without the consent to Release lnformation Form being signed. Reports and/or disclosures of individually identifiable health information (excluding 38 U.S.C. 7332 information) may be made to local law enforcement agency or local adulUchild care protective services agency as long as the requirements of the privacy laws are met. The VAHCS will adhere to the provisions of Kentucky child and adult protection laws.

(c) ln all cases where VA staff report suspected abuse, neglect or exploitation to VA police as possible criminal activity, the VA staff shall also call the Cabinet for Health and Family Services to make the initial verbal report for investigation.

(d) Completion of the "lnitial Assessment for AdulVChild Protective Services" note will initiate a Social Work Consult for follow-up review of that case by Social Work staff.

a. Physical Assault: An active physical expression of violence and mental distress that results in bodily harm to another person. This includes gunshot wounds, cuts, fractures, poisonings, and other such cases of physical damage caused by the commission of a crime of violence. All such cases should immediately be reported to the VA Police for investigation.

(1) History will include but not be limited to the survivor's report, delays in seeking treatment, and explanations of injuries that are inconsistent with medical findings.

Other warning signs include increased use of the Emergency Room, Mental Health or other medical services, self-neglect or unkempt appearance, inappropriate concern about the nature or extent of injuries, being afraid to speak in the perpetrator's presence, "accident prone" history, self-destructive behaviors, suicide attempts, depression, and recurring physical ailments including pain.

(2) Physical findings include: Fractures, dislocations, lacerations, abrasions, injuries to the head and face, and any other injuries sustained in an assault. Other signs may include bruises, burns, changes in mental status, emotional withdrawal, and suicide attempt.

(1) lmmediate and long{erm impacts on physical health and well-being include trauma such as soreness, bruising, or vaginal/rectal bleeding. Some impacts may include gastrointestinal irritability, fatigue, intense startle reactions, disturbed eating patterns, and abnormal sleeping patterns. Other impacts may be pregnancy, HIV or other infections. Use of alcohol and other drugs as a means of escape, sleep aid or medication may be observed as a result of Sexual molestatlon and rape. Post-traumatic stress disorder (PTSD), chronic anxiety; self-blame, mistrust of others, depression, risk of suicide, sexual dysfunction, and physical distress may also be observed as potential symptoms of such trauma.

(2) Treatment: Acute sexual assault (within 72 hours) will be treated in the Emergency Department, unless it is an inpatient Veteran. Appropriate arrangements for staff to contact the Veteran survivor will be made. Staff will contact Ampersand for an advocate for the Veteran survivor. After an appropriate medical screening exam, suryivor may be referred to the Fayefte County police Sexual Assault Response Team (SART) for forensic examination by the SART Sexual Assault Nurse Examiner (SANE). The survivor will be escorted to the University of Kentucky for the exam. lf the survivor chooses otherwise, a SANE exam will be provided at this facility by a provider or trained Sexual Assault Nurse Examiner, with appropriate supervision. Follow-up treatment should be arranged at

5. DEFINITIONS:

b. Sexual molestation and rape: An active physical expression of violence and mental distress that is directed towards the genitals of another non-consenting person.

Healthcare practitioners should be aware that only a minority of rape survivors seek assistance after they have been raped and others may seek medical care without disclosing the assault has occurred.

the VA Health Care System as needed. Female victims should be refened to the Primary Care-Women's Health Clinic for their follow-up treatment. Any evidence, such as clothing, should not be discarded and the proper chain of custody should be followed. ln the event the exam is completed at this facility, the evidence will be collected by the police in the jurisdiction the assault occurred or in the VA police evidence room.

c. Domestic Abuse or Spouse Abuse: This is violence directed towards one or both parties in a significant relationship, including lntimate Partner Violence (lPV). House Bill 309 in 2017 removed domestic violence/lPV as a mandatory abuse report, opting instead for mandatory education on domestic violence and community resources. VA professionals will meet the requirements of KRS 209 as follows;

(1) lf a VA professional has reasonable cause to believe that a client may have experienced domestic violence and abuse, or dating violence and abuse, the professional shall provide the survivor with educational materials related to domestic violence and abuse, or dating violence and abuse including information about how he or she may access regional domestic violence programs or rape crisis centers. lnformation about how to access protective orders can be found in KRS 2094 (Attachment B). The Cabinet for Health, Families, and Children are no longer accepting domestic violence or IPV abuse reports per KRS 209.

(3) VA staff will discuss with the alleged survivor the choice of whether to have VA staff file a police report with their local law enforcement office.

(a) lf the survivor agrees to a report being filed, the VA staff shall call the survivor's local law enforcement office to file the report and document the survivor's agreement. VA staff also will document to which law enforcement agency the report was called.

(b) lf the survivor declines the offer of VA staff to call the Police to file a report, VA staff will document both the discussion of the option of making a report and the refusal of the alleged suryivor to let VA file a police report.

(4) lf the alleged survivor is a Veteran receiving care at the VA, prior to EHR documentation of alleqed IPV/DV , VA staff must inquire if the alleged perpekator is also a Veteran receiving treatment at the VA and/or is the alleged perpetrator listed as the Nel:t of Kin, Health Care Power of Attorney or emergency contact in the Victim's record. If the alleged perpetrator currently has access to the survivor's EHR, VA staff must offer the following privacy options:

(2) The VA professional will provide information regarding how to access regional domestic violence programs, rape crisis centers, and information pertaining to protective orders. VA staff may assist the alleged survivor in calling community agencies for assistance in shelter or other needs.

1. During regular business hours, to Health Adminiskation Service (HAS) (VHALEX HAS New Patient Request).

2. After hours, weekends and holidays, to the Administrative Officer on Duty

(AOD) (VHALEX HAS/AODS).

3. VA Staff are to call HAS and/or AOD when a decision has been made to implement a collateral chart.

(b) lf the alleged perpetrator is not a Veteran receiving care at the VA, but may have access to the survivor's VA record as a listed contact, VA staff will offer to assist the survivor Veteran to remove the alleged perpetrator's name and contact information from the survivor Veteran's chart and/or to request their chart be marked sensitive, including the survivor's My HealtheVet if applicable. lf the survivor Veteran agrees to either or both actions, VA Staff need to document these options were offered and the actions taken. This is done by the following:

1. During regular business hours, call the Privacy Officer. ln their absence, call the Chief of Health lnformation Management Service (HIMS) to request the chart be marked sensitive and/or send an encrypted e mail to HAS at (VHALEX HAS New Patient Request) to remove the alleged perpetrator as a contact in the survivor Veteran's record.

2. After hours, notify the AOD at VHALEX HAS/AODS

(c) lf the alleged survivor Veteran has a current Advance Directive note and Advance Directive document on file designating the alleged perpetrator as Health Care Power of Attorney, and the survivor Veteran wishes to rescind that document and Designation, VA staff are to document this as an addendum note in the existing Advance Directive note in the survivor Veteran's EHR. Alert this addendum note to either HAS staff or AOD depending upon the tour of duty, for immediate action. VA Staff will also follow Step 't., 2., and 3., in ( ) (b) above to notify either HAS or the AOD to remove the Alleged perpetrator as a contact in

(a) lf the alleged perpetrator is a Veteran receiving care at the VA, VA Staff will offer to the survivor to establish a collateral chart to the alleged perpetrator Veteran's chart so that the EHR note documenting the alleged abuse reported by the survivor cannot be seen by the alleged perpetrator. This is accomplished by the VA staff sending an encrypted email with the survivor's name, social security number, date of birth, gender, address, phone number, and the alleged perpetrator Veteran's name and social security number as follows:

3. VA Staff will call Privacy Officer or Chief, HIMS or designee, or AOD near the end of the business day to communicate the urgency of survivor's request.

November 30,2020 MCP'122-09 the survivor Veteran's record. ln addition, VA staff are to advise the survivor Veteran of the option of completing a new Advance Directive and offer to help the survivor call a VA Social Worker during regular Business hours. Also give Social Work staff contact information after hours to the survivor for follow-up.

(d) lf the alleged survivor is neither a Veteran nor a CHAMPVA patient at the VA, then the VA staff will seek to establish a chart for the survivor and offer to have it marked sensitive as specified in (4) b above. The survivor also will be advised of the option to not list the alleged perpetrator as a contact person. Even if the alleged perpetrator is Health Care POA or legal Next of Kin, the survivor will be offered the opportunity to list an emergency contact instead, if there are no other Next of Kin contacts. VA staff will send an encrypted email with survivor's name, social security number, date of birth, gender, address, and phone numbers to establish a record prior to documentation of alleged IPV/DV documentation.

2. Mental Health/Psychiatric lndicators: lnability to cope, suicide attempts or gestures, depression, panic attacks, alcohol or drug abuse, and PTSD reactions.

d. Elder Abuse or Neglect: This is abuse or neglect directed towards a person of 65 years or older. This also includes financial exploitation of such individuals. This can include neglect or abuse found in nursing home patients by VA professional staff or reported by others. Please refer to section 5(a) (Procedures) of this medical center policy for reporting procedures.

e. Child Abuse or Neglect: Federal law defines child abuse as "physical or sexual abuse or neglect of a child." (See 42 U.S.C. 1 3001a (5) for this definition). For purposes of the statutory requirement to report child abuse, the term is further defined as "the

1. Medical indicators may include: lnjuries to head and neck, injuries to breasts and broken ribs (usually from kicking), arm injuries (from warding off blows or pulling), strangulation, back or spine injuries, and soft{issue injuries. Other indicators may be injuries from weapons, burns (cigarette, appliances, rug, scalding liquids, chemicals), chronic pain, gynecologic infections, frequent use of tranquilizers or pain medications. If the survivor shows signs of exacerbation or poorly controlled chronic illnesses such as asthma, diabetes, arthritis, and heart disease these may be indicators.

3. Behavioral lndicators: Discrepancies between injury and explanation, delay in seeking medical care, partner accompanies patient and answers all questions directed at the patient, reluctance of patient to speak in front of partner, and intense irrational jealousy or possessiveness expressed by partner or reported by patient. Other indicators might be denial or minimization of violence, exaggerated sense of personal responsibility for the relationship, and history of child abuse or neglect.

physical or mental injury, sexual abuse or exploitation, or negligent treatment of a child".

ln turn, the term "sexual abuse" includes "the employment [or] use of a child to engage in sexual exploitation of children," and the term 'exploitation' means child pornography or child prostitution." (See 42 U.S.C. 1 3031 (c)(1), 13031(c)(4) -(6) for these definitions and for more information.)

f. Military Sexual Trauma

(1) Military sexual trauma (MST) is defined as "psychological trauma, which in the judgment of a mental health professional employed by the Department (of Veterans Affairs), resulted from a physical assault of a sexual nature, baftery of a sexual nature, or sexual harassment which while the Veteran was serving on active duty or active duty for training." Sexual harassment is further defined as "repeated, unsolicited verbal or physical contact of a sexual nature, which is threatening in character".

(2) Veterans and eligible individuals who report having experienced MST are eligible for VA care, including medications, for all physical and mental health conditions determined by their VA provider to be related to experiences of MST.

Veterans and potentially eligible individuals who may have conditions related to MST that require care, but who are not eligible for other VHA care, are able to be evaluated by a clinician to determine the applicability of the free care benefit.

(3) Providers of clinical services must comply with the requirement to screen every Veteran and potentially eligible individual (male or female) for a history of MST experiences. MST screening must be done using the MST clinical reminder in the EHR, which must be activated for all Veterans and potentially eligible individuals.

Screening is to be conducted in appropriate clinical settings in a sensitive manner by clinical staff. Screenings are not to be conducted by clerks or health technicians

(4) Veterans and eligible individuals with a positive history of MST must be offered MST counseling and appropriately referred for evaluation and treatment as clinically indicated. The healthcare provider must document the referral was made or clearly note if declined by Veteran.

(5) Appropriate physical and mental health care available for conditions related to MST are provided within the VAHCS campuses and VA Outpatient Clinics. MST counseling and related mental health services are provided by appropriately trained and qualified Mental Health Service staff. Referral to the local Readjustment Counseling Service (Vet Center) may also be an appropriate option. Care in the Community is available under certain circumstances as detailed in VHA Directive 2010-033 dated July 14,2010.

(6) Mental Health and other health care personnel must receive appropriate education and training about MST-related issues appropriate to their role with Veterans and potentially eligible individuals. All medical center staff will be

I provided a basic general orientation to MST and made aware of the screening requirement.

(7) lnformation regarding VA services related to MST and access information will be displayed in appropriate places within the medical center and CBOCs. This will be provided as part of facility Oukeach activities.

(8) The designated facility MST Coordinator serves as a point of contact for Veterans and other individuals about MST-related services at the facility and CBOCS. On MST issues, the MST Coordinator is a resource for facility and CBOC staff, providing information and assisting with resolution of system problems.

6. REFERENCES:

902 KAR 2:020 Reportable Disease Surveillance. Retrieved Nov 24, 2020irom https:/iapps. leq islature. kv ov I law I kar I 902 I 002 I 020.pdf

902 KAR 20:016 Hospitals, Operations and Services. Retrieved Nov 24, 2020from https://apps.l eq islature. ky.qov/laWkar 190210201016.pdf

Kentucky Revised Statute 209-2017 Chapter 209 Protection of Adults, 20'17. Retrieved Nov 23, 2020 from htips://l ustia.com/codes/kentuckv l2017lchaoter-2091a

Title42 U.S.C. Section 13001 (a) (5), The Public Health and Welfare Chapter 132, Victims of Child Abuse Subchapter 1, lmproving investigation and Prosecution of Child Abuse Cases, Defi nitions.

Title42 U.S.C. Section 13031 (c) (1), 13031 (c) (4)-(6), Dugto ReportSuspected Child Abuse.

VHA Directive 1101.05(2), Emergency Medicine, page 44, dated September 2,20j6.

VHA Directive 1 1 15.01 , Military Sexual Trauma Counseling;

VHA Directive I 198, lntimate Partner Violence Assistance Program, dated January 24, 2019.

VHA Directive 1 1 99, Reporting Cases of Abuse and Neglect, dated Novemb er 28, 2017

VHA Directive 1330.01, Health Care Services for Women Veterans, dated February 15, 2017.

VHA Directive 2012-026, Sexual Assaults and Other Defined Public Safety lncidents, dated September 27, 2012.

I

7. RESCISSION: 122-09, Patient Abuse, Neglect, Sexual Trauma, and Threats of Violence, November 23,2020, is rescinded.

8. REVIEW: Chief, Social Work Service (122).

9. RECERTIF]CATION:

This MCP is scheduled for recertification on or before the last working day of October 2025. This MCP will continue to serve as local policy until it is recertified or rescinded.

ln the vent of contradiction with national policy, the national policy supersedes and controls.

10. stG AUTH

X Greq oi 5,F HE

Directo r

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: This document was up loaded to the Lexinqton VAHCS Document Control Svstem on MCP's are available at the following link:

ATTACHMENT A

rNrTtAL ASSESSMENT FOR ADULT (AND CHTLD) PROTECTTVE SERVTCES

REFERRAL

Per paragraph (4: a-f) of KRS 209.030, titled Administrative requlations -- Reports of adult abuse, neqlect or exploitation , the following information is required for an initial report of suspected abuse, neglect or exploitation, if known:

1. Name of alleged victim:

2. Age/birth date of alleged victim:

3. Name/address/phone numbers of any person(s) responsible for the care of the above alleged victim:

4. Name/address/phone numbers and any other identifying information regarding the alleged perpetrato(s), if known:

Nofe: For #5 and # 6 below, please record sim ple facts and q uoted statements of what was heard or obse rved throu o VO UT SENSES that led to OUT SUS icion of USEh D ab neolect or exploitation

5. Nature and Extent of the alleged abuse, neglect or exploitation, including any reports/evidence of previous abuse, neglect or exploitation:

6. Any other information which might be helpful in establishing the cause of abuse, neglect or exploitation:

7. Staff person entering this note (name, title, service, phone numbers):

8. lf the above information was called into Protective Services by the staff person above, please record the Protective Services number called, the name of the Protective Services lntake/After-Hours worker taking the call and their verbal response to your referral:

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