I. Purpose:
Hillcrest is committed to providing safe and effective services to our students. Safety and effectiveness go hand in hand. In order for students to be able to concentrate on their treatment and education, they must feel safe and protected. In order for staff to be able to focus on the care, treatment and education of students, they must feel safe and protected. HEC is committed to satisfying the expectations of its licensing agencies, and will consult agency liaisons as necessary to assure regulatory compliance and clear communication.

 

II. Objectives:
Allegations of abuse and neglect, injuries, emergencies, and incidents resulting in the potential for harm are taken very seriously. These types of events warrant a timely, thorough, and objective internal investigation, if indicated by the initial inquiry or by the nature of the incident itself. All events/incidents requiring an Internal Investigation require the immediate notification of the Executive Director and/or Senior Vice President or designee. The Executive Director and/or Senior Vice President will determine if the investigation will be conducted by the campus administration, the Director of Quality Assurance, or any other neutral party designee. If at any time during the Internal Investigation it appears that any illegal or criminal behavior was performed, the investigation will either cease or proceed under the direction of the local law enforcement.

 

III. Procedure:

 
1. A formal Internal Investigation must be conducted should any of the following occur:

 
• Allegation or complaint of abuse or neglect as defined by MA DCF and/or student’s referring state
• Major injury to student resulting in EMT response, emergency treatment, and/or physician intervention
• Allegation or complaint of sexual contact between students
• Missing child
• Vehicular accident
• Significant property destruction
• Stolen property
• Fire
• Discovery of illegal contraband (i.e. illegal substance, weapon, etc.)
• Significant program disruption (i.e. group violence, students left unattended, etc.)
• Sentinel events as defined by the JOINT COMMISSION
• A request for internal investigation by any state licensing and / or external reporting agencies
• Any other occasion when the Program Director determines the need for a formal investigation

 

2. Upon discovery of any of the above scenarios, a campus administrator, supervisor, or designee will contact the Program Director or Administrator on-call to determine the need for an Internal Investigation.

 

3. If it is determined that criteria is met for Internal Investigation, the Executive Director and/or Senior Vice President or designee will be notified immediately. The Executive Director and/or Senior Vice President, in conjunction with the Program Director and Quality Assurance Director, will determine if the event meets criteria for a reportable incident. This determination may be made initially, or at any time during the investigation as more information is gathered.

 
4. An official Internal Investigation File will be established by the Program Director, Quality Assurance Director, or designee, which minimally MUST include an official Internal Investigation Form, an Internal Investigation/Notification Checklist, and copies of any initial statements/reports related to the matter. The file will be given an Investigation ID code number using the campus initials first, the date of the incident/complaint second, and lastly, the primary student’s first and last initials. In the unlikely event that more than one investigation begins on the same day involving the same student, the code numbers will end with “a”, “b”, respectively. The Program Director (if investigation is conducted by campus administration) or Executive Director, Senior Vice President, and/or Quality Assurance Director (if investigation is conducted by a neutral party) will oversee all activities related to the investigation according to the timelines outlined in the Internal Investigation/Notification Checklist. The Executive Director, Senior Vice President, and/or the Director of Quality Assurance will provide support and supervision throughout the investigation as needed.

 
5. Immediate Response to Complaint / Incident

 

A. Campus administration and / or supervisory staff must collect initial written statements from all staff involved or may be witness to any reported incident or allegation. An HEC Formal Witness Statement form must be utilized when obtaining statements from staff related to an Internal Investigation. Depending on the nature of the event / incident and the initial information gathered, staff alleged to have been involved may be immediately suspended with or without pay pending the outcome of the investigation.
B. The Program Director, On-Call Administrator, or designee with consideration for causing as little disruption as possible to the daily routines of the students in the program, evaluate the situation and immediately take appropriate action to assure the health and safety of the students involved in the reportable incident / allegation and any other students similarly situated in the program. If determined to be necessary, the Program Director, On-Call Administrator, or designee will take additional action to prevent future acts of abuse and neglect including temporary removal of the student(s) from the program and/or reassignment of the student(s) within the facility. This would be conducted as an emergency measure if it is determined that there is a risk to the health or safety of such student(s) remaining at the program. If such immediate action is taken, HEC immediately make notifications to any Massachusetts licensing agencies and any out of state agencies appropriate to the student referring state, including agencies such as the New York State Justice Center for the Protection of People with Special Needs and the commissioner.
C. In all instances of alleged physical or sexual abuse, the campus Head Nurse or designee must be contacted immediately for medical consultation. The campus Head Nurse, agency Director of Nursing, and/or designee will determine if further medical treatment and / or evaluation is to be conducted by an off campus medical facility. The nursing department will document any evidence regarding a student’s body check and/or treatment provided to the student. The campus Program Director and / or Head Nurse will collect any and all documentation received by an outside medical facility for evidence of a reportable incident.
D. The Program Director, Director of Quality Assurance, or designee will begin to preserve any potential evidence to include, but not limited to:
• Securing the area wherein the suspected reportable incident occurred, if appropriate, and preserve relevant video surveillance material.
• Obtain sufficient documentation of the allegation / incident such as written initial statements, incident reports, medical information, etc.
• Conduct interviews and provide written summaries from all staff and students involved and / or witness to the reportable incident, when appropriate.
E. The program will provide counseling to the student(s) involved in any reportable incident or allegation, if appropriate. This will be conducted by the students primary clinician or designee, if possible.
F. Throughout the process of the internal investigation, HEC will cooperate with any external investigation conducted by DCF, DEEC, DESE, and law enforcement. In addition, HEC will cooperate with any out of state external investigation appropriate to the student(s) referring state. This includes cooperation with the New York Justice Center by complying with the procedures for the protection of New York state referred students in subdivision 5 of section 490 of the New York Social Services Law.

 
6. Notifications

 
A. The Program Director, the Director of Quality Assurance or designee will assure that all external communication / notification occurs in accordance with Hillcrest policy, state and licensing regulations, and the requirements of the students referring state agencies. These notifications are to include:
• Immediate report to the DCF local screening unit or state hotline if evenings or weekend.
• Notification to DEEC and DESE licensures via agency portals.
• Immediate reports to any out of state agencies appropriate to the student(s) referring state. These out of state agencies may include agencies such as the New York State Justice Center for the Protection of People with Special Needs, New York State Education Department and any local New York social services district, school district, and/or state agency funding the placement of any student involved in a reportable incident.
• Notification to student(s) legal guardian.
• Submit all required and requested initial documentation to all Massachusetts and out of state agencies.
B. The Program Director, Director of Quality Assurance, or designee will promptly make notifications to DCF, DEEC, DESE and any out of state agencies appropriate to the student(s) referring state including agencies such as the New York State Justice Center for the Protection of People with Special Needs regarding the resignation or termination of a subject of a report of alleged abuse or neglect from his or her position while an investigation is pending.

 
7. Internal Investigation Completion

 
A. The Program Director, Director of Quality Assurance, or designee will complete the HEC Internal Investigation Report Form upon the conclusion of the internal investigation. Every applicable item on both the Investigation/Notification Procedure Checklist and the Internal Investigation Report Form is critical and must be thoroughly completed in order to properly conduct, document and conclude any Internal Investigation. The Executive Director, Senior Vice President, and/ or the Director of Quality Assurance (if investigation is conducted by program administration) will assure the timely completion of every applicable item of the official Internal Investigation Report Form. The official Internal Investigation Report Form is required to be completed for all HEC Internal Investigations. The Executive Director, Senior Vice President, and/ or the Director of Quality Assurance (if investigation is conducted by program administration) will also assure the completion of every applicable item in sections I, II, and III of the Investigation / Notification Procedure Checklist according to the time lines required by all reporting and licensing agencies.
B. Upon completion of the internal investigation, the internal investigation report form and investigation / notification procedure checklist, the entire original file will be forwarded to the Executive Director and/or Senior Vice President for review and signature. Per DEEC, only reports signed by the Executive Director and/or Senior Vice President will be considered to be the “official” version of the investigation report.

C. If appropriate, The Program Director or designee will implement a program corrective / preventative action plan if the internal investigation determines that such abuse or neglect may have attributed in whole or in part to noncompliance by the program. In addition, the Program Director or designee will take such action as is necessary to prevent future acts of abuse and neglect including such actions as provision of increased training and/or supervision to staff pertinent to the prevention and remediation of abuse and neglect.
D. The Program Director, Director of Quality Assurance, or designee will submit a copy of the internal investigation report form and appropriate attachments to DCF, DEEC, DESE, and any out of state agencies appropriate to the student(s) referring state including agencies such as the New York State Justice Center for the Protection of People with Special Needs and the New York State Education Department.
E. The Program Director, Director of Quality Assurance, or designee will take appropriate action to support a request for additional information from DCF, DEEC, DESE and any out of state agencies appropriate to the student(s) referring state including agencies such as the New York State Justice Center for the Protection of People with Special Needs and the New York State Education Department.

 
8. Incident Closure

 
A. Obtain documentation of recommended and/or required corrective action from DCF, DEEC, DESE, and any out of state agencies appropriate to the student(s) referring state including agencies such as the New York State Justice Center for the Protection of People with Special Needs and the New York State Education Department. If corrective action is required due to noncompliance by the program that may in whole or in part contributed to the reported event of abuse or neglect, the program will implement a plan of prevention and remediation. This shall address at minimum the areas in which the program has been found to be out of compliance and shall indicate the manner in which the program will come into compliance. The corrective action plan shall be developed and all documentation will be submitted for approval to the appropriate agency within the timeframe specified on the report.
B. Obtain documentation of external investigation closure from DCF, DEEC, DESE, and any out of state agencies appropriate to the student(s) referring state including agencies such as the New York State Justice Center for the Protection of People with Special Needs. Any Massachusetts agency external investigation reports will be forwarded to out of state agencies appropriate to the student(s) referring state no later than 90 days, if made available to HEC.
C. The Executive Director, Senior Vice President, Director of Quality Assurance or designee will assure the timely completion of every item in incident closure section of the Investigation/Notification Procedure Checklist, and will maintain the entire original file at the Administrative Offices throughout the remainder of the process.