Home Health Agency (HHA) Reporting Form — Abuse, Neglect and Exploitation Investigation Report and Alleged Perpetrator Information Form

What this rule requires your agency to do

• 1The report must include the facility's investigative report and all supporting documentation, all original notarized witness statements regarding abuse/neglect/exploitation alleged to have been committed by a facility staff member, a copy of the alleged perpetrator's license/certificate if a licensed or certified health professional, and a completed Alleged Perpetrator Information form if applicable.(Home Health Agency (HHA) Reporting Form — Abuse, Neglect and Exploitation Investigation Report and Alleged Perpetrator Information Form)
• 2The reporting facility must submit the completed investigation and all attachments by certified mail or FAX within 5 working days to the KDHE Health Facilities Program Director, Bureau of Community Health Systems, 1000 SW Jackson Suite 330, Topeka, KS 66612 (FAX 785-559-4250).(Home Health Agency (HHA) Reporting Form — Abuse, Neglect and Exploitation Investigation Report and Alleged Perpetrator Information Form)
• 3For a licensed nurse alleged perpetrator, the facility must indicate whether a report was made to the Kansas State Board of Nursing, and must document any law-enforcement notification (date and case number).(Home Health Agency (HHA) Reporting Form — Abuse, Neglect and Exploitation Investigation Report and Alleged Perpetrator Information Form)
• 4For the alleged perpetrator, the facility must attach evidence of pre-employment screening and ANE training for that employee, a copy of the certificate or license, and the alleged perpetrator's notarized statement, and report date of hire and any suspension or termination dates.(Home Health Agency (HHA) Reporting Form — Abuse, Neglect and Exploitation Investigation Report and Alleged Perpetrator Information Form)
• 5The facility must document the corrective actions taken in response to the incident and the plan for monitoring the ongoing effectiveness of the corrective action plan through its QA program, and the person completing the investigation must certify that all information given is true and correct.(Home Health Agency (HHA) Reporting Form — Abuse, Neglect and Exploitation Investigation Report and Alleged Perpetrator Information Form)