Mandatory Reporting Policy - CareGroup Portal

Beth Israel Deaconess Medical Center
BIDMC Manual
Title: Mandatory Reporting of Alleged Abuse and Neglect
Policy #: PR-11
Purpose:
To provide clear guidelines for mandatory reporting to state agencies of suspected
abuse and/or neglect of children, elders, and disabled persons.
Policy Statement:
Society has determined that it is important to protect vulnerable members of society.
Thus, the legislature has enacted statutes requiring that all health care providers and
other human service professionals (collectively, “mandated reporters”) report
suspected abuse or neglect of children, elders, and disabled persons to appropriate
state agencies. All clinical staff engaged in the examination, care, or treatment
of patients are mandated reporters.
It is the responsibility of all clinical staff members to assess the need for reporting of
suspected abuse and neglect and, if indicated, to file such a report with the
appropriate state agency. Guidelines regarding the identification, assessment, and
documentation of suspected abuse and neglect are contained in the Manual of
Clinical Practice, Patient Assessment (PA) Section. Links to this manual are as
follows:
PA-12 Child Protection Procedure
PA-12 Child Abuse Report
PA-13 Elder Protection Procedure
PA-13 Elder Abuse Mandated Reporter Form
Fax Report Incident/Abuse Form
PA-14 Disabled Patient Protection Procedure
PA-14 Disabled Patient Report Form
HIPPA Disclosure Tracking Tool Link:
http://home.caregroup.org/templatesnew/departments/BID/Privacy/uploaded_docume
nts/AccountingofDisclosureTrackingTools.xls
The decision to report should be made in consultation with the social work
department, hospital administration, and if needed, the legal department.
For consultation, contact:
The Social Work Department
Monday – Friday, 8:30 am – 5:00 pm at (617) 667-3421
PR-11 Page 1 of 5

Saturday – Sunday, 9:00 am – 5:00 pm via page operator
A Clinical Advisor or Medical Center Administrator (AOC) is on call evenings and
nights at (617) 667-4700 via page operator.
The Legal Department is available at (617) 667-1894 or via page operator at (617)
667-4700.
In preparation for contacting the appropriate state agency to file a report of
suspected abuse or neglect, the following information should be obtained:
a. Identifying information about family and/or caretakers.
b. Description of the situation of suspected abuse and/or neglect.
c. Name, address, telephone number, and age of child, elder, or disabled
person.
d. Name, telephone numbers, and institutional address of mandated
reporter.
e. Name and phone number of state agency’s intake worker. (Write this
information on top of the reporting form.)
After consultation, if the decision has been made to file, this procedure should be
followed:
Procedure for Filing Mandated Report:
All reports of suspected abuse and/or neglect can be filed twenty-four hours a day,
seven days a week with the appropriate state agency.
Child Protection (children 0 to 18 years of age):
A 51A report (the statutory reference for the child protection reporting requirement) is
filed in two parts:
1. Verbal Report –
• Telephone the Department of Social Services Intake Office in the child’s
hometown during normal business hours (9am – 5 pm, Monday –
Friday). The appropriate Department of Social Services Intake Office
may be identified by contacting the Boston Regional Office at (617)
822-4840.
• On weekends, evenings, and nights, contact the Child-At-Risk Hotline
at (800) 792-5200.
1. Written Report –
• File within 48 hours of the verbal report.
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• 51A forms are available online as an attachment to this policy.
• Fax a copy of 51A report to the Beth Israel Deaconess Medical Center
Social Work Department at (617) 667-8701. Send the original by
interoffice mail to the Social Work Department, “E/RO200”. The Social
Work Department will forward the report, with a cover letter, to the
Massachusetts Department of Social Service.
• A copy of the report will be retained by the Social Work Department.
• Complete a HIPPA Disclosure Tracking form and send/fax to BIDMC
Health Information Management. (see instructions/attachment at the
end of this policy)
• Do not place a copy of the 51A report in the medical record.
• Whenever possible and consistent with the safety of the child, the
parent/caretakers should be informed of the decision to report.
Elder Protection (persons age 60 and above):
The location of the elder’s residence (i.e., community vs. nursing home) will determine
to which designated protective service agency the report of suspected abuse or
neglect of an elder should be made:
1. Verbal Reports:
• For elders living in the community:
Monday – Friday, 9am – 5pm, telephone ETHOS at (617) 522-
6700
Weekends, evenings, and nights, telephone the Elder Abuse
Hotline at (800) 922-2275
• For elders living in a nursing home:
Monday – Friday, 9am – 5pm, telephone the Department of
Public Health at (617) 753-8150.
Weekends, evenings, and nights, telephone (800) 462-5540.
2. Written Reports:
• File within 48 hours of the verbal report.
• Reporting forms are available online as an attachment to this
policy.
A copy of the report should be faxed to the Beth Israel
Deaconess Medical Center Social Work Department (617) 667-
8701. Send the original via interoffice mail to the Social Work
PR-11 Page 3 of 5

Department, “E/RO200”. The Social Work Department will
forward the report, with a cover letter, to the appropriate state
agency.
• A copy of the report will be retained in the Social Work
Department
• Complete a HIPPA Disclosure Tracking form and send/fax to
BIDMC Health Information Management (see end of this policy
for information/attachment).
• Do not place a copy of the report in the medical record.
Disabled Persons Protection (persons between the ages of 18 and 59):
Reports are filed through the Disabled Persons Protection Commission.
1. Verbal Reports:
• Telephone the Disabled Persons Protection Hotline at (800) 426-9009
Monday – Friday, 9 am – 5 pm and evenings, nights, and weekends.
2. Written Reports:
• File within 48 hours of the verbal report.
• Reporting forms are available online as an attachment to this policy.
• A copy of the form should be faxed to the Beth Israel Deaconess
Medical Center Social Work Department at (617) 667-8701. Send the
original by interoffice mail to the Social Work Department “E/RO200”.
The Social Work Department will forward the report, with a cover letter,
to the appropriate state agency.
• A copy will be retained in the Social Work Department.
• Complete a HIPPA Disclosure tracking form and send/fax to BIDMC
Health Information Management. (HIM fax: 7-5432).
• Do not place a copy of the report in the medical record.
• Whenever possible and consistent with the safety of the patient, the
patient should be informed of the decision to report. A patient can limit
disclosure of certain communications. In these circumstances, consult
with the legal department.
PR-11 Page 4 of 5

Vice President Sponsor: Dianne J. Anderson, VP Patient Care Services
Approved By:
⌧ Operations Council: 6/21/04
Michael Epstein, MD
Chief Operating Officer
Requestor Name: Barbara Sarnoff Lee, Director Social Work
Original Date Approved: 10/01
Next Review Date: 10/01/07
Revised: 6/04, 10/04, 3/07
Eliminated: (Date)
PR-11 Page 5 of 5