Critical Incident Report User Guide Form 470-4698 - Iowa Medicaid ...

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Iowa Department of Human ServicesIMPA Incident Reporting FormIMPA Users Guide – Revised May, 2010ABUSE REPORT OR RESTRICTIONFigure 27: Abuse Report or Restriction, Part 2 Incident TypeThe Abuse Report or Restrictions section of the Incident Type gathers information about:CHILD ABUSE: - Verbal or written statement made to the Department by a person or persons who suspect that childabuse has occurred. (441 IAC 175.21)DEPENDENT ADULT ABUSE: - Verbal or written statement made to the Department by a person or persons who suspectthat dependent adult abuse has occurred. Dependent adult means a person 18 years of age or older who is unable toprotect their own interests or unable to perform adequately or obtain services necessary to meet essential humanneeds, as a result of a physical or mental condition which requires assistance from another. (441 IAC 176.1)RESTRICTION: - Rights restrictions means limitations not imposed on the general public in the areas of communication,mobility, finances, medical or mental health treatment, intimacy, privacy, type of work, religion, place of residence, andpeople with whom the individual using the service may share a residence. (441 IAC 24.1)Select all that apply. For each category indicate whether the member was the victim or the perpetrator.VICTIM: - The member is considered the victim if they suffer from a destructive, injurious action or they aredeceived and cheated by the dishonesty of another person or persons.PERPETRATOR: - The member is considered the perpetrator if they are reasonably suspected, charged or convictedof being responsible for an illegal act.Figure 28: Suspected Child Abuse, Part 2 Incident TypeFields in the Abuse Report or Restrictions section of theIncident Type include:SUSPECTED CHILD ABUSE:PHYSICAL INJURY: - Any non-accidental physical injury,or injury which is at variance with the history given ofit, suffered by a child as the results of the acts oromissions of a person responsible for the care of thechild. (Iowa Code section 232.68(2) (a)).MENTAL INJURY: - Any mental injury to a child’sintellectual or psychological capacity as evidenced by an observable and substantial impairment in the child’sability to function within that child’s normal range of performance and behavior as the result of the acts oromissions of a person responsible for the care of the child, if the impairment is diagnosed and confirmed by alicensed physician or qualified mental health professional. (Iowa Code section 232.68(2)(b))SEXUAL ABUSE: - The commission of sexual offense with or to a child pursuant to Iowa Code Chapter 709,section 726.2 or section 728.12, subsections 1, as a result of the acts or omissions of the person responsible forthe care of the child. Notwithstanding Iowa Code section 702.5, the commission of a sexual offense under thisPage 22
Iowa Department of Human ServicesIMPA Incident Reporting FormIMPA Users Guide – Revised May, 2010paragraph includes any sexual offense referred to in this paragraph with or to a person under the age of 18years. (Iowa Code section 232.68(2)(c)).DENIAL OF CRITICAL CARE: - The failure on the part of a person responsible for the care of a child to provide forthe adequate food, shelter, clothing, or other care necessary for the child’s health and welfare when financiallyable to do so, or when offered financial or other reasonable means to do so. A parent or guardian legitimatelypracticing religious beliefs who does not provide specified medical treatment for a child for that reason aloneshall not be considered abusing the child. However, this provision does not preclude a court from ordering thatmedical service be provided to the child where the child’s health requires it. (Iowa Code section 232.68(2)(d)).PRESENCE OF ILLEGAL DRUGS: - An illegal drug is present in a child’s body as a direct and foreseeableconsequence of the acts or omissions of the person responsible for the care of the child. (Iowa Code section232.68(2)(f))MANUFACTURE OR POSSESSION OF A DANGEROUS SUBSTANCE: - The person responsible for the care of achild:o Has manufactured a dangerous substance in the presence of the child, oro Possesses a product containing ephedrine, its salts, optical isomers, salts of optical isomers, orpseudoephedrine, its salts, optical isomers, salts of optical isomers in the presence of the child with theintent to use the product as a precursor or an intermediary to a dangerous substance.COHABITATION WITH A REGISTERED SEX OFFENDER: - Abuse is committed when a caretaker of a childknowingly allows unsupervised access to a child by a person required to register on the sex offender registry orknowingly allows registered sex offender to have custody or control of a child. The finding of this type of abusedoes not apply if:o The registered sex offender is the caretaker’s child or a minor, oro The caretaker is married to and living with the registered sex offender.For this type of abuse only, a “child” is a person under the age of 14 unless the child has a physical or mentaldisability.Figure 29: Suspected Dependent Adult Abuse, Part 2 Incident TypePlease select all that apply. Fields in the Abuse Report or Restrictions section of the Incident Type include SUSPECTEDDEPENDENT ADULT ABUSE due to the willful or negligent acts or omissions of a caretaker:PHYSICAL INJURY: - Physical injury to, or injury which is at variance with the history given of the injury, orunreasonable confinement, unreasonable punishment, or assault of a dependent adult.SEXUAL ABUSE: - The commission of a sexual offense under Iowa Code chapter 709 or Iowa Code section 726.2with or against a dependent adult.SELF-DENIAL OF CRITICAL CARE: - The deprivation of the minimum food, shelter, clothing, supervision, physicalor mental health care, and other care necessary to maintain a dependent adult’s life or health as a result of theacts or omissions of the dependent adult.EXPLOITATION: - Exploitation of a dependent adult which means the act or process of taking unfair advantage ofa dependent adult or the adult’s physical or financial resources for one’s own personal or pecuniary profit,without the informed consent of the dependent adult, including theft, by the use of undue influence,harassment, duress, deception, false representation, or false pretenses.DENIAL OF CRITICAL CARE: - The deprivation of the minimum food, shelter, clothing, supervision, physical ormental health care and other care necessary to maintain a dependent adult’s life or health.Page 23
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