Respite Services Respite is provided to

Respite Services
Respite is provided to consumers who are unable to care for themselves, because of the absence
or need for relief of those persons normally providing the care and supervision. Respite is only
furnished on a temporary/short-term basis. Respite services are provided in a variety of settings
and may be provided on an hourly (up to eight hours in a calendar day) or daily (eight hours or
more in a calendar day) basis.
In order to be eligible for Respite Service funded by the IR/RD Home and Community Based
Waiver, Community Supports Waiver or HASCI Waiver, the consumer must: (1) Be eligible to
receive services from DDSN; (2) Be enrolled in the IR/RD, CSW or HASCI Waivers; and (3)
Have the need for respite documented in their Plan of Supports with “waiver” noted as the
funding source; and (4) have been approved to receive respite services through the waiver.
Respite care may be provided in a variety of settings through the IR/RD, CSW and HASCI
waivers. The setting of the respite services is chosen by the recipient and his/her family. The
choice of setting must be documented by the recipient or his/her represented using the choice of
location form.
The respite services provider cannot be the consumer’s primary caregiver as defined by the State
of South Carolina. The following people cannot be paid to provide respite services:
• A primary caregiver;
• The spouse of the consumer;
• A parent, step parent, foster parent or legal guardian of a minor consumer;
• A court appointed guardian of an adult consumer;
• Parent or stepparent of adult waiver recipient who resides in the same household
as the consumer.
The following are examples of people who may be paid to provide respite if all other provider
qualifications are met and he/she is not one of the consumer’s primary caregivers:
• A parent of an adult consumer who does not reside in the consumer’s household;
• A non-legally responsible family member (sibling, grandparent, aunt, uncle, etc.).
Family members wishing to receive payment for respite services rendered must acknowledge
that they are not a primary caregiver of the consumer and that they are not legally responsible for
the consumer. The Statement of Legal Responsibility for Respite Services (MR/RD Form 31)
form must be used to document this and must be completed prior to the authorization of services.
This information should be placed in the consumers file.
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BC/RF
Respite Certification Checklist for Home and Community Based Waivers
After reading the information contained in this packet, carefully review the Certification Checklist for requirements that must be met
prior to certification. SLED background checks and DSS Central Registry checks should be completed prior to pursuing any other
requirements.
At least 18 years of age and able to read, write and speak English
Caregiver Information Sheet
SLED Check- SLED checks must be current within 120 days prior to certification and can be obtained through the following
website: http://www.sled.state.sc.us/sled/default.asp?Category=CATCH_SSN&Service=CR
DSS Central Registry Check- Can be mailed or taken to the South Carolina Department of Social Services (DSS). Ask for a
“Central Registry Check”. The process takes several weeks when mailed.
Physical Exam- Verification attesting to the fact that you are physically capable of performing work responsibilities
(specifically, you are capable of aiding an individual with activities of daily living) and free of communicable diseases.
TB Test- A two-step TB test must be completed within 30 days prior to certification. TB tests can be obtained at doctor’s
offices and local health departments. Two-step TB testing requires two separate visits for injections and two separate visits
for test reading.
10- Year Driving Record- Required for respite providers who will be transporting individuals in their care. The decision as
to whether or not you will be transporting individuals is made between you and the family for whom you provide services.
First Aid Training – The training may be obtained through certified first aid training courses such as American Heart
Association or American Red Cross. Resources are also available online:
http://www.redcross.org/courses/index.jsp?scode=PSG00000E017&subcode=paidregistration&_requestid=914036
http://www.onlinecprcertification.net/firstaidcourse.php
Abuse/Neglect, Confidentiality, Supervision– The training documents as well as the competency test for Abuse/Neglect are
included in this packet.
Signs and Symptoms of Illness, Fire Safety, and Understanding Disabilities Training-This should be documented on the
Home Supports Caregiver Certification Form. The family may provide this training and determine competency or exempt a
caregiver from receiving training.
Home Supports Caregiver Certification Form
Statement of Legal Responsibility Form
HIPAA Privacy Notice and Acknowledgement of Receipt
** Documents should be mailed to Babcock Center to the attention of Tonya Bradford. All required documentation should be
submitted at one time.
11/14
BC/RF
Household Employee/Respite Caregiver Information
Household Employee Name: _____________________________________________________
Household Employee Address: ___________________________________________________
___________________________________________________
Household Employee Telephone Number: __________________________________________
Household Employee Emergency Number: _________________________________________
Employer of Record
(Participant/Responsible Party) Name: _____________________________________________
Employer of Record
(Participant/Responsible Party) Address: ___________________________________________
___________________________________________
Employer of Record
(Participant/Responsible Party) Telephone Number: __________________________________
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BC/RF
South Carolina Department of Social Services
CONSENT TO RELEASE INFORMATION
With my signature below, I consent for the South Carolina Department of Social Services to conduct a one-time search of the records
indicated below to determine whether they contain information that I was the perpetrator of harm to a child and to release information
found to the individual/organization named below.
I understand that the information provided may prove to be unfavorable to me. I agree to hold the South Carolina Department of
Social Services and its staff harmless from liability associated with release of information requested on this form. If it appears to me
that the information has not been updated or is otherwise inaccurate, I agree to notify the Department immediately.
SECTION I. Purpose for Request
A. I am requesting a search of the Central Registry of Child Abuse and Neglect and the Department’s database of records of Child
Abuse and Neglect cases in connection with:
n becoming or remaining a foster parent or potential adoptive parent; or
n becoming or remaining an employee of or a member of the state or a local foster care review board; or
n becoming an employee or volunteer for the South Carolina Guardian ad Litem Program or Richland County CASA.
n I am requesting a search ONLY of the Central Registry of Child Abuse and Neglect for a purpose of
B. X
.
SECTION II. Mail Results To:
ATTN:
TEL. NO:
SECTION III. Central Registry Check Fees: Please
CASH).
n Non-Profit Entities………………………….$8.00
n For-Profit Entities…………………..……. $25.00
n
X State Agencies………………………..........$8.00
n Schools……..............................................$8.00
R appropriate box and include payment. Check or Money Order (NO
n Name Changes…………………............$8.00
n Other (Individuals, etc.).…….................$8.00
n Private Adoption Investigations…........$25.00
SECTION IV. Please print legibly or type the following: First, Middle and Last Name (NO INITIALS)
Name:
DOB:
Maiden/Aliases:
Name Change:
Place of Birth:
SSN: (See instructions)
Current Address:
Sex:
Race:
Previous Address: (See instructions)
SECTION V. Your signature MUST be witnessed or notarized. Please mail appropriate payment and form for processing to:
South Carolina Dept. of Social Services, ATTN: Cashier, 1535 Confederate Avenue, P.O. Box 1520, Columbia, SC 29202-1520.
Signature of Applicant
Date
Signature of Notary or Witness
Date
SECTION VI. RESULTS: THIS SECTION IS TO BE COMPLETED ONLY BY AUTHORIZED DSS EMPLOYEES OF THE
DEPARTMENT.
n The name is not included as a perpetrator on the Central Registry of Child Abuse and Neglect.
n The request has been received. Additional research will be required to respond to the request. Thirty to sixty days may be
required. Please call
if you have any questions.
n The name is included as a perpetrator on the Central Registry of Child Abuse and Neglect.
n The name is included as a perpetrator in the Department’s database of records of child abuse and neglect cases. See attached
correspondence.
Authorized DSS Employee
DSS Form 3072 (AUG 13) Edition of SEP 08 is obsolete.
Date
INSTRUCTIONS FOR DSS FORM 3072 – CONSENT TO RELEASE INFORMATION
PLEASE DO NOT ALTER THIS FORM IN ANY WAY
SECTION I: Purpose for Request: To provide authorization for the SC Department of Social Services to conduct a
search of the State Central Registry of Child Abuse and Neglect and/or the DSS Database and to release results. Please
indicate the purpose of the search by checking R in the appropriate box.
SECTION II: Mail Results To: Please ensure that you type or stamp the return address next to, “MAIL RESULTS TO,”
on this form. Please include the contact person’s name and telephone number.
SECTION III: Central Registry Fee: Please check
R appropriate fee box.
SECTION IV: Please type or print legibly the following information:
• Name: Provide complete spelling of name to include the first, middle and last name - NO INITIALS.
• Name Change: List the new name(s).
• Date of Birth: Month/Day/Year
• Sex: (Self Explanatory)
• Race: (Self Explanatory)
• Social Security Number: All the information requested on this form is necessary in order to conduct a thorough
search. Providing your Social Security Number (SSN) is optional, but it is recommended that you provide your SSN to
assist with the research. Your SSN will be used only to conduct what we hope will be a thorough central registry/data
base check and will not be given to any person than indicated agency or entity.
• Place of Birth: Provide the name of the State you were born in.
• Current Address: Provide your current residence.
• Previous Address: If current address is less than 7 years; list other addresses, States, Countries you have resided in
for the past seven years. Use separate sheet if necessary.
SECTION V: Mail payment; completed Form 3072 Consent to Release Information, and a stamped addressed envelope to:
South Carolina Department of Social Services
Attention: CASHIER
1535 Confederate Avenue
P.O. Box 1520
Columbia, SC 29202-1520
•
Signature of Applicant: Requesting the applicant’s original signature for a one-time search of the State Central
Registry of Child Abuse and Neglect and/or the DSS Database and to release results.
•
Signature of Witness or Notary: The applicant’s signature must be witnessed or notarized prior to submitting for
processing.
PLEASE CALL (803) 898-7229 IF YOU NEED ASSISTANCE COMPLETING THIS FORM.
After receipt by cashier and processing of payment, the Central Registry/DATA BASE check will be completed by
authorized DSS personnel in the Division of Human Services.
DSS personnel in the Division of Human Services must do the following:
1. Conduct Central Registry check and/or Database search in accordance with Section I. A or B.
2. Check appropriate results box.
2. Sign and date form; stamp, “confidential” on envelope and mail to return address, Section II.
Distribution
Results of the search will be sent ONLY to the individual or organization specified in Section II of this form.
DSS Form 3072 (AUG 13)
PAGE 2
SC Department of Disabilities & Special Needs
Home Supports
Caregiver Certification
Effective February 2008
The following guidelines apply to Individual Rehabilitation Supports, MR/RD Waiver and HASCI
Waiver funded home supports that are provided by DSN Boards. These guidelines supersede portions
of DDSN Administrative Agency Standard relating to Staff Development and Training (136), and all
other policies, directives, or guidelines regarding the provision of designated services through a DDSN
Home and Community Based Waiver or Rehabilitation Supports. All payments must be made
directly to the provider of the service (caregiver) and cannot be made to the family or the recipient.
Payments will not be made for services rendered by relatives of the recipient as defined by South
Carolina Medicaid Home and Community Based Waiver policy. Services covered in these guidelines
are:
MR/RD Waiver:
HASCI Waiver:
CS Waiver:
PDD Waiver:
Respite, Companion, and Homemaker
Respite, Personal Assistance/Attendant
Respite, In-Home Support
Respite, Companion, and Homemaker
Minimum qualifications for caregivers:
 The caregiver will have the ability to read, write and speak English.
 The caregiver will be at least 18 years of age.
 The caregiver will be capable of aiding in the activities of daily living (not required for
Rehabilitation Supports caregiver if not part of the job for which he/she is hired).
 The caregiver will be capable of following a plan of service with minimal supervision.
 The caregiver will have no record of abuse, neglect, crimes committed against other people or
felonious convictions of any kind.
 The caregiver will be free from communicable and contagious diseases.
 The caregiver must maintain a valid Driver’s License and be insurable (if driving is required as
part of the job).
 The caregiver will document hours worked and the nature of the tasks performed. The waiver
recipient or his/her designee (i.e., parent, sibling, etc.) will verify the documentation.
 If providing Personal Assistance/Attendant Care supervision will be provided by a RN or as
otherwise allowed within the provision of state law.
 The caregiver will demonstrate competency in required training. (See attached training
requirements for caregivers.) Training will include the attached minimum guidelines for
training as well as any special techniques/procedures/equipment required to adequately provide
services for the individual prior to assuming responsibility.
Training Requirements for Caregivers
All caregivers must have the skills and abilities to provide quality services for the people they serve.
Minimally, caregivers must demonstrate competency in the following areas (taken directly from the preservice curriculum) before services are provided. Hours in parentheses are estimates of the time needed to
achieve competency and may be higher or lower depending on the existing skill level of the caregiver and the
skills required for serving a particular waiver recipient.
1. Confidentiality, Accountability and Prevention of Abuse and Neglect (1.5 hours)
2. First Aid (4 hours)
3. Fire Safety/Disaster Preparedness related to the specific location of services (1 hour)
4. Understanding Disabilities (MR/RD and Autism)
OR
Orientation to Head and Spinal Cord Injuries (HASCI): This training must be specifically related to the
person/family needing services (1-3 hours)
5. Signs and Symptoms of Illness and Seizures (1 hour)
The following describes two ways in which caregivers can demonstrate competency:
1. Taking and passing tests (curriculum) in the above categories. Tests may be taken as part of DSN Board
Training or may be taken when training does not occur.
2. Recipient/responsible party can approve caregiver competency for items 3 - 5 above, but cannot sign off on
items 1 or 2.
Caregivers must also demonstrate competency in any person-specific special techniques / procedures /
equipment and must be oriented to the habits, preferences, and interests of the person. Caregivers must be
able to communicate with the recipient. The recipient or family will typically provide this training to the
caregiver. DSN providers, however, should allow access, upon request, to training classes and/or assist with
caregiver training. The recipient/responsible party, prior to services beginning, must complete the attached
Caregiver Certification form for each caregiver. This form along with supporting documentation (training
records, tests, etc.) will be maintained by the local DSN Board.
HOME SUPPORTS
CAREGIVER CERTIFICATION
Caregiver Information:
Name:
Social Security Number:
Address:
Phone Number:
The above named caregiver has demonstrated competency in the areas noted below
through the successful completion of training or by exemption from the training as
approved by me.
Name of Training
Training/Date
Confidentiality, Accountability &
Prevention of Abuse and Neglect
First Aid
Exemption/Date
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
Fire Safety/Disaster Preparedness
Understanding Disabilities
(MR/RDs, MR/RD or Autism)
OR
Orientation to Head and Spinal
Cord Injuries
Signs and Symptoms of Illness &
Seizures
The above named caregiver has been oriented to the habits, preferences and interests of
and is competent to perform the tasks
needed to provide his/her care.
Consumer/Responsible Party
Relationship of Responsible Party to Consumer
Date
South Carolina Department of Disabilities and Special Needs
Statement of Legal Responsibility for Respite Services
Participant’s Name:
SSN:
Date of Birth:
Respite Care is defined as care provided to the SCDDSN participant in the absence of the caregiver or when the
caregiver needs relief from the responsibilities of care giving. A participant’s primary caregiver(s) cannot
provide Respite. The primary caregiver(s) of the participant noted above is/are:
__________________________________________________________________________________
__________________________________________________________________________________
South Carolina Medicaid Policy prohibits anyone who is legally responsible for the health care decisions of
another to be paid for rendering Respite Care to that person. If you are legally responsible for the health care
decisions of the participant noted above, you cannot be paid for providing Respite Care.
By signing this statement you acknowledge that:


you are not a primary caregiver of the participant noted above, AND
you are not legally responsible for his/her health care decisions.
I am not a primary caregiver of the person noted above, and I am not legally responsible for the person noted
above.
__________________________________________________
Signature
_______________________________________________
Printed Name
MR/RD Form 31 (Revised 12/09)
______________________
Date
BABCOCK CENTER, INC.
NOTICE OF PRIVACY PRACTICES
Effective: April 14, 2003
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This notice will tell you how we may use and disclose protected health information about you. Protected health
information means any health information about you that identifies you or for which there is a reasonable basis to
believe the information can be used to identify you. In the header above, that information is referred to as “medical
information.” In this notice, we simply call all of that protected health information, “health information.”
This notice also will tell you about your rights and our duties with respect to health information about you. In addition,
it will tell you how to complain to us if you believe we have violated your privacy rights.
How We May Use and Disclose Health Information About You.
We use and disclose health information about you for a number of different purposes. Each of those purposes is described below.
For Treatment.
We may use health information about you to provide, coordinate or manage the services, supports, and health care you receive
from us and other providers. We may disclose health information about you to doctors, nurses, qualified mental retardation
professionals (QMRPs), coordinators, psychologists, social workers, direct support staff and other agency staff, volunteers and other
persons who are involved in supporting you or providing care. We may consult with other health care providers concerning you and,
as part of the consultation, share your health information with them. For example, staff may discuss your information to develop and
carry out your individual service plan. Staff may share information to coordinate needed services, such as medical tests,
transportation to a doctor’s visit, physical therapy, etc. Staff may need to disclose health information to entities outside of our
organization (for example, another provider or a state/local agency) to obtain new services for you.
For Payment.
We may use and disclose health information about you so we can be paid for the services we provide to you. This can include
billing a third party payor, such as Medicaid or other state agency (for example, the South Carolina Department of Disabilities and
Special Needs or SCDDSN), or your insurance company. For example, we may need to provide the state Medicaid program
information about the services we provide to you so we will be reimbursed for those services. We also may need to provide the state
Medicaid program with information to ensure you are eligible for the medical assistance program.
For Health Care Operations.
We may use and disclose health information about you for our own operations. These are necessary for us to operate BABCOCK
CENTER and to maintain quality for the people we support. For example, we may use health information about you to review the
services we provide and the performance of our employees supporting you. We may disclose health information about you to train
our staff and volunteers. We also may use the information to study ways to more efficiently manage our organization, for
accreditation or licensing activities, or for our compliance program.
How We Will Contact You.
Unless you tell us otherwise in writing, we may contact you by either telephone or by mail at either your home or your workplace. At
either location, we may leave messages for you on the answering machine or voice mail. If you want to request that we
communicate to you in a certain way or at a certain location, see “Right to Receive Confidential Communications” on page 3 of this
Notice.
Appointment Reminders.
We may use and disclose health information about you to contact you to remind you of an appointment for treatment or services.
Treatment and Service Alternatives.
We may use and disclose health information about you to contact you about treatment and service alternatives that may be of
interest to you.
Health Related Benefits and Services.
We may use and disclose health information about you to contact you about health-related benefits and services that may be of
interest to you.
BABCOCK CENTER Directory.
We may include your name, your location in our facility, your condition described in general terms, and your religious affiliation in our
directory while you receive services. This information, except for your religious affiliation, may be released to people who ask for
you by name. Your religious affiliation may be given to members of the clergy, such as a minister, priest or rabbi. If you do not want
included in our facility directory, or you want to restrict the information we include in the directory, you must notify the Privacy Officer
at 2725 Banny Jones Ave. West Columbia. S.C. 29170 of your objection.
Disclosures to Family and Others.
We may disclose to a parent/guardian, personal representative, family member, other relative, a close personal friend, or any other
person identified by you, health information about you that is directly relevant to that person’s involvement with the services and
supports you receive or payment for those services and supports. We also may use or disclose health information about you to
notify, or assist in notifying, those persons of your location, general condition, or death. If there is a family member, other relative, or
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close personal friend that you do not want use to disclose health information about you to, please contact the Privacy Officer at 2725
Banny Jones Ave. West Columbia. S.C. 29170.
Disaster Relief.
We may use or disclose health information about you to a public or private entity authorized by law or by its charter to assist in
disaster relief efforts. This will be done to coordinate with those entities in notifying a parent/guardian, personal representative,
family member, other relative, close personal friend, or other person identified by you of your location, general condition or death.
Required by Law.
We may use or disclose health information about you when we are required to do so by law.
Public Health Activities.
We may disclose health information about you for public health activities and purposes. This includes reporting health information to
a public health authority that is authorized by law to collect or receive the information for purposes of preventing or controlling
disease. Or, one that is authorized to receive reports of child abuse and neglect. It also includes reporting for purposes of activities
related to the quality, safety or effectiveness of a United States Food and Drug administration regulated product or activity.
Victims of Abuse, Neglect or Domestic Violence.
We may disclose health information about you to a government authority authorized by law to receive reports of abuse, neglect, or
domestic violence, if we believe you are a victim of abuse, neglect, or domestic violence. This will occur to the extent the disclosure
is: (a) required by law; (b) agreed to by you or your personal representative; or, (c) authorized by law and we believe the disclosure
is necessary to prevent serious harm to you or to other potential victims, or, if you are incapacitated and certain other conditions are
met, a law enforcement or other public official represents that immediate enforcement activity depends on the disclosure.
Health Oversight Activities.
We may disclose health information about you to a health oversight agency for activities authorized by law, including audits,
investigations, inspections, licensure or disciplinary actions. These and similar types of activities are necessary for appropriate
oversight of the health care system, government benefit programs, and entities subject to various government regulations.
Judicial and Administrative Proceedings.
We may disclose health information about you in the course of any judicial or administrative proceeding in response to an order of
the court or administrative tribunal. We also may disclose health information about you in response to a subpoena, discovery
request, or other legal process but only if efforts have been made to tell you about the request or to obtain an order protecting the
information to be disclosed.
Disclosures for Law Enforcement Purposes.
We may disclose health information about you to a law enforcement official for law enforcement purposes:
a) As required by law.
b) In response to a court, grand jury or administrative order, warrant or subpoena.
c) To identify or locate a suspect, fugitive, material witness or missing person.
d) About an actual or suspected victim of a crime and that person agrees to the disclosure. If we are unable to obtain
that person’s agreement, in limited circumstances, the information may still be disclosed.
e) To alert law enforcement officials to a death if we suspect the death may have resulted from criminal conduct.
f)
About crimes that occur at our facility.
g) To report a crime in emergency circumstances.
Coroners and Medical Examiners.
We may disclose health information about you to a coroner or medical examiner for purposes such as identifying a deceased person
and determining cause of death.
Funeral Directors.
We may disclose health information about you to funeral directors as necessary for them to carry out their duties.
Organ, Eye or Tissue Donation.
To facilitate organ, eye or tissue donation and transplantation, we may disclose health information about you to organ procurement
organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue.
Research.
Under certain circumstances, we may use or disclose health information about you for research. Before we disclose health
information for research, the research will have been approved through an approval process that evaluates the needs of the
research project with your needs for privacy of your health information. We may, however, disclose health information about you to
a person who is preparing to conduct research to permit them to prepare for the project, but no health information will leave
BABCOCK CENTER during that person’s review of the information.
To Avert Serious Threat to Health or Safety.
We may use or disclose protected health information about you if we believe the use or disclosure is necessary to prevent or lessen
a serious or imminent threat to the health or safety of a person or the public. We also may release information about you if we
believe the disclosure is necessary for law enforcement authorities to identify or apprehend an individual who admitted participation
in a violent crime or who is an escapee from a correctional institution or from lawful custody.
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Military.
If you are a member of the Armed Forces, we may use and disclose health information about you for activities deemed necessary
by the appropriate military command authorities to assure the proper execution of the military mission. We may also release
information about foreign military personnel to the appropriate foreign military authority for the same purposes.
National Security and Intelligence.
We may disclose health information about you to authorized federal officials for the conduct of intelligence, counter-intelligence, and
other national security activities authorized by law.
Protective Services for the President.
We may disclose health information about you to authorized federal officials so they can provide protection to the President of the
United States, certain other federal officials, or foreign heads of state.
Security Clearances.
We may use health information about you to make medical suitability determinations and may disclose the results to officials in the
United States Department of State for purposes of a required security clearance or service abroad.
Inmates; Persons in Custody.
We may disclose health information about you to a correctional institution or law enforcement official having custody of you. The
disclosure will be made if the disclosure is necessary: (a) to provide health care to you; (b) for the health and safety of others; or, (c)
the safety, security and good order of the correctional institution.
Workers Compensation.
We may disclose health information about you to the extent necessary to comply with workers’ compensation and similar laws that
provide benefits for work-related injuries or illness without regard to fault.
Other Uses and Disclosures.
Other uses and disclosures will be made only with your written authorization. You may revoke such an authorization at any time by
notifying the Privacy Officer at 2725 Banny Jones Ave. West Columbia. S.C. 29170 in writing of your desire to revoke it. However,
if you revoke such an authorization, it will not have any affect on actions taken by us in reliance on it.
Your Rights With Respect to Health Information About You.
You have the following rights with respect to health information that we maintain about you.
Right to Request Restrictions.
You have the right to request that we restrict the uses or disclosures of health information about you to carry out treatment,
payment, or health care operations. You also have the right to request that we restrict the uses or disclosures we make to: (a) a
family member, other relative, a close personal friend or any other person identified by you; or, (b) for to public or private entities for
disaster relief efforts. For example, you could ask that we not disclose health information about you to your brother or sister.
To request a restriction, you may do so at any time. If you request a restriction, you should do so to the Privacy Officer (2725 Banny
Jones Ave. West Columbia. S.C. 29170. 803-799-1970) and tell us: (a) what information you want to limit; (b) whether you want to
limit use or disclosure or both; and, (c) to whom you want the limits to apply (for example, disclosures to your spouse).
We are not required to agree to any requested restriction. However, if we do agree, we will follow that restriction unless the
information is needed to provide emergency treatment. Even if we agree to a restriction, either you or we can later terminate the
restriction.
Right to Receive Confidential Communications.
You have the right to request that we communicate health information about you to you in a certain way or at a certain location. For
example, you can ask that we only contact you by mail or at work. We will not require you to tell us why you are asking for the
confidential communication.
If you want to request confidential communication, you must do so in writing to Privacy Officer at 2725 Banny Jones Ave. West
Columbia. S.C. 29170. Your request must state how or where you can be contacted.
We will accommodate your request. However, we may, if necessary, require information from you concerning how payment will be
handled. We also may require an alternate address or other method to contact you.
Right to Inspect and Copy.
With a few very limited exceptions, such as psychotherapy notes, you have the right to inspect and obtain a copy of health
information about you.
To inspect or copy health information about you, you must submit your request in writing to Privacy Officer at 2725 Banny Jones
Ave. West Columbia. S.C. 29170. Your request should state specifically what health information you want to inspect or copy. If you
request a copy of the information, we may charge a fee for the costs of copying and, if you ask that it be mailed to you, the cost of
mailing.
We will act on your request within thirty (30) calendar days after we receive your request. If we grant your request, in whole or in
part, we will inform you of our acceptance of your request and provide access and copying.
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We may deny your request to inspect and copy health information if the health information involved is:
a.
Psychotherapy notes;
b.
Information compiled in anticipation of, or use in, a civil, criminal or administrative action or proceeding;
If we deny your request, we will inform you of the basis for the denial, how you may have our denial reviewed, and how you may
complain. If you request a review of our denial, it will conducted by a licensed health care professional designed by us who was not
directly involved in the denial. We will comply with the outcome of that review.
Right to Amend.
You have the right to ask us to amend health information about you. You have this right for so long as the health information is
maintained by us.
To request an amendment, you must submit your request in writing to Privacy Officer at 2725 Banny Jones Ave. West Columbia.
S.C. 29170. Your request must state the amendment desired and provide a reason in support of that amendment.
We will act on your request within sixty (60) calendar days after we receive your request. If we grant your request, in whole or in
part, we will inform you of our acceptance of your request and provide access and copying.
If we grant the request, in whole or in part, we will seek your identification of and agreement to share the amendment with relevant
other persons. We also will make the appropriate amendment to the health information by appending or otherwise providing a link
to the amendment.
We may deny your request to amend health information about you. We may deny your request if it is not in writing and does not
provide a reason in support of the amendment. In addition, we may deny your request to amend health information if we determine
that the information:
a.
Was not created by us, unless the person or entity that created the information is no longer available to act on
the requested amendment;
b.
Is not part of the health information maintained by us;
c.
Would not be available for you to inspect or copy; or,
d.
Is accurate and complete.
If we deny your request, we will inform you of the basis for the denial. You will have the right to submit a statement of disagreeing
with our denial. Your statement may not exceed 5 pages. We may prepare a rebuttal to that statement. Your request for
amendment, our denial of the request, your statement of disagreement, if any, and our rebuttal, if any, will then be appended to the
health information involved or otherwise linked to it. All of that will then be included with any subsequent disclosure of the
information, or, at our election, we may include a summary of any of that information.
If you do not submit a statement of disagreement, you may ask that we include your request for amendment and our denial with any
future disclosures of the information. We will include your request for amendment and our denial (or a summary of that information)
with any subsequent disclosure of the health information involved.
You also will have the right to complain about our denial of your request.
Right to an Accounting of Disclosures.
You have the right to receive an accounting of disclosures of health information about you. The accounting may be for up to six (6)
years prior to the date on which you request the accounting but not before April 14, 2003.
Certain types of disclosures are not included in such an accounting:
a.
Disclosures to carry out treatment, payment and health care operations;
b.
Disclosures of your health information made to you;
c.
Disclosures that are incident to another use or disclosure;
d.
Disclosures that you have authorized;
e.
Disclosures for our facility directory or to persons involved in your care;
f.
Disclosures for disaster relief purposes;
g.
Disclosures for national security or intelligence purposes;
h.
Disclosures to correctional institutions or law enforcement officials;
i.
Disclosures that are part of a limited data set for purposes of research, public health, or health care operations
(a limited data set is where things that would directly identify you have been removed.
j.
Disclosures made prior to April 14, 2003.
Under certain circumstances your right to an accounting of disclosures to a law enforcement official or a health oversight agency
may be suspended. Should you request an accounting during the period of time your right is suspended, the accounting would not
include the disclosure or disclosures to a law enforcement official or to a health oversight agency.
To request an accounting of disclosures, you must submit your request in writing to Privacy Officer 2725 Banny Jones Ave. West
Columbia. S.C. 29170. Your request must state a time period for the disclosures. It may not be longer than six (6) years from the
date we receive your request and my not include dates before April 14, 2003.
Babcock Center, Inc.
HIPAA Notice – ver 1.0.0. 4 (12/03/09)
Page 4
Usually, we will act on your request within sixty (60) calendar days after we receive your request. Within that time, we will either
provide the accounting of disclosures to you or give you a written statement of when we will provide the accounting and why the
delay is necessary.
There is no charge for the first accounting we provide to you in any twelve (12) month period. For additional accountings, we may
charge you for the cost of providing the list. If there will be a charge, we will notify you of the cost involved and give you an
opportunity to withdraw or modify your request to avoid or reduce the fee.
Right to Copy of this Notice.
You have the right to obtain a paper copy of our Notice of Privacy Practices. You may obtain a paper copy even though you agreed
to receive the notice electronically. You may request a copy of our Notice of Privacy Practices at any time.
You may obtain a copy of our Notice of Privacy Practices over the Internet at our web site, www.babcockcenter.org.
To obtain a paper copy of this notice, contact to Privacy Officer at 2725 Banny Jones Ave. West Columbia. S.C. 29170.
Our Duties
Generally.
We are required by law to maintain the privacy of health information about you and to provide individuals with notice of our legal
duties and privacy practices with respect to health information.
We are required to abide by the terms of our Notice of Privacy Practices in effect at the time.
Our Right to Change Notice of Privacy Practices.
We reserve the right to change this Notice of Privacy Practices. We reserve the right to make the new notice’s provisions effective
for all health information that we maintain, including that created or received by us prior to the effective date of the new notice.
Availability of Notice of Privacy Practices.
A copy of our current Notice of Privacy Practices will be posted at our Mary L.Duffie Administration Building (2725 Banny Jones Ave.
West Columbia. S.C. 29170). A copy of the current notice also will be posted on our web site, www.babcockcenter.org.
At any time, you may obtain a copy of the current Notice of Privacy Practices by contacting Privacy Officer at 2725 Banny Jones
Ave. West Columbia. S.C. 29170.
Effective Date of Notice.
The effective date of the notice will be stated on the first page of the notice.
Complaints.
You may complain to us and to the United States Secretary of Health and Human Services if you believe your privacy rights have
been violated by us.
To file a complaint with us, contact the Deputy Executive Director or Privacy Officer at 2725 Banny Jones Ave. West Columbia.
S.C. 29170. All complaints should be submitted in writing.
To file a complaint with the United States Secretary of Health and Human Services, send your complaint to him or her in care of:
Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, D.C. 20201.
You will not be retaliated against for filing a complaint.
Questions and Information.
If you have any questions or want more information concerning this Notice of Privacy Practices, please contact the Privacy Officer
by mail at 2725 Banny Jones Ave. West Columbia. S.C. 29170 or by phone at (803) 799-1970.
Babcock Center, Inc.
HIPAA Notice – ver. 1.0.0. 4 (12/03/09)
Page 5
Acknowledgment of Receipt of Notice of Privacy Practices
This is to acknowledge my receipt of Babcock Center’s Notice of Privacy Practices (effective date
April 14, 2003) on the date stated below.
_______________________________________
Date of Individual’s or Personal Representative’s
Signature
_______________________________________
Signature of Individual or
Personal Representative
_______________________________________
Individual’s Name
_______________________________________
_______________________________________
Individual’s Address
_______________________________________
Name of Personal Representative
(If applicable)
_______________________________________
_______________________________________
Description of Representative’s Authority
to Act for the Individual
(If applicable)
Babcock Center, Inc.
HIPAA Receipt of Notice Acknowledgement
Version 1.0.0.1 – 02/2003
NoticeReceiptAcknowledge.doc
10/9/2014
Training for Mandated Reporters
This powerpoint represents an attempt to condense a large amount of complex information into a
useful training and reference tool. Although every effort has been made to ensure that the
information presented is both correct and current, these materials should be used only as
overviews and general guidance, not necessarily as a basis for making specific decisions in a
particular case. The powerpoint is not a legal document, nor is it intended to fully explain all of
the provisions or exclusions of the relevant laws, regulations, and rulings that may impact cases
involving abuse of the elderly or other vulnerable adults. The powerpoint should not be viewed
as rendering any legal, accounting, or other professional advice, nor does it necessarily reflect
the policies or legal positions of any individual, agency, or other entity participating in its
preparation or use.
Note: This training is also not intended as a replacement for any agency or entity's internal
training regarding protection for vulnerable adults or any other conventional training.
Each agency or entity has policies and procedures for handling these cases.
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Omnibus Adult Protection Act often referred to as
OAPA
Found at South Carolina Code Ann §43-35-5
et.seq.
A person who is 18 years or older
Has a physical or mental condition
◦ which substantially impairs the person from adequately
providing for his/her own care
Due to infirmities of aging, including:
◦ organic brain damage
◦ advanced age, and
◦ physical, mental, or emotional dysfunction
A resident of a facility is a vulnerable adult
SC Code Ann. §43-35-10
http://www.scstatehouse.gov/code/t43c035.php#43-35-10
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Physician
Nurse
Dentist
Optometrist
Medical examiner
Coroner
Other medical, Mental Health or
allied health professional
Christian Science Practitioner
Religious Healer
School teacher
Counselor
Psychologist
Mental Health Specialist
Intellectual Disability
Specialist
Social or public assistance
worker
Caregiver
Staff or volunteer of an
adult day care center or
facility
Law enforcement officer
SC Code Ann. § 43-35-25
May take photographs of trauma to vulnerable adult
Notify the person in charge of the photographs
Investigative entity or law enforcement may cause to
be performed a radiological examination or medical
examination without consent
All photographs, x-rays, and results of medical
examinations must be provided to law enforcement or
the investigative entity upon request
SC Code Ann. §43-35-30
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A caregiver is someone who:
◦
◦
◦
◦
◦
Provides care to a vulnerable adult
With or without compensation
Temporary or permanent
Full or part-time
Can be a
relative
household member
day care personnel
adult foster home sponsor
personnel of a public or private institution or facility
SC Code Ann. §43-35-10(2)
A facility directly operated by or contracted for
operation by:
◦ Department of Mental Health
◦ Department of Disabilities and Special Needs
Nursing care facility
Community residential care facility
Psychiatric hospital
Residential program operated or contracted for
operation by:
◦
◦
Department of Mental Health
Department of Disabilities and Special Needs
S C Code Ann § 43-35-10(4),(12),(13)
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Physical Abuse
◦ Including sexual abuse
Psychological Abuse
Neglect
Exploitation
SC Code Ann. § 43-35-25
Physical Abuse
◦ Intentional infliction or allowing to be inflicted injury
Types of Physical Abuse
◦
◦
◦
◦
◦
◦
◦
◦
◦
Slapping
Hitting
Kicking
Biting
Choking
Pinching
Burning
Actual or attempted sexual battery
Use of medication outside the standards of medical practice
SC Code Ann. § 43-35-10(8)
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Use of restricted or physically intrusive procedure
to control behavior
◦ For punishment
◦ Not used as part of a written plan of care from a
physician or qualified professional
SC Code Ann. § 43-35-10(8)
Staff at a nursing home beat resident with a belt
when resident tried to smear feces on the staff at
bath time. Staff on the next shift noticed the
marks and reported the incident.
Resident could not communicate, but based on
physical evidence collected and interviews with
staff, the abuser confessed to the physical abuse.
Staff was charged with Abuse of Vulnerable Adult.
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A vulnerable adult may be furnished non-medical
remedial treatment by spiritual means through
prayer if the vulnerable adult has practiced this in
his/her religion
SC Code Ann. § 43-35-13
Altercations or acts of assault between two
vulnerable adults
Refer to the agency policy and report to local law
enforcement
SC Code Ann. §43-35-10(8)
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Actual or
Attempted sexual battery
◦ Defined by SC Code Ann. §16-3-651
Sexual battery means sexual intercourse, cunnilingus, fellatio, anal
intercourse, or any intrusion, however slight, of any part of a
person's body or of any object into the genital or anal openings of
another person's body, except when such intrusion is accomplished
for medically recognized treatment or diagnostic purposes.
SC Code Ann. § 43-35-10(8)
Deliberately subjecting a vulnerable adult to threats or
Harassment or other forms of intimidating behavior
◦
◦
◦
◦
◦
◦
causing fear
humiliation
degradation
agitation
confusion, or
other forms of serious emotional distress.
Example: Resident who is fearful of the dark and that fear is
used as punishment
SC Code Ann. § 43-35-10(10)
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Causing or requiring a vulnerable adult
to engage in activity or labor
◦ which is improper, unlawful, or
◦ against the vulnerable adult’s reasonable
and rational wishes
SC Code Ann. § 43-35-10(3)(a)
Improper, unlawful, or unauthorized use of the
◦ funds
◦ assets
◦ property
◦ power of attorney
◦ guardianship, or
◦ conservatorship of a vulnerable adult
by a person for the profit or advantage of that person or
another person
SC Code Ann. § 43-35-10(3)(b)
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Causing a vulnerable adult to purchase goods or services
for the profit or advantage of the seller or another person through
◦ undue influence,
◦ harassment,
◦ duress,
◦ force,
◦ coercion, or
◦ swindling by overreaching
◦ cheating, or
◦ defrauding the vulnerable adult
◦ through cunning arts or devices
that delude the vulnerable adult and cause him to lose money or other
property
SC Code Ann. § 43-35-10(3)(c)
Requiring a vulnerable adult to participate in an
activity or labor
◦ which is a part of a written plan of care or
◦ which is prescribed or authorized by a licensed physician
attending the patient
SC Code Ann. § 43-35-10(3)
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A resident of a nursing home had her bills paid by
her daughter who had power of attorney.
The daughter stopped paying the bills and the
resident’s account went into arrears at the nursing
home.
Daughter used her mother’s money to buy a new
car and to install a swimming pool at her house.
Daughter was charged with Financial Exploitation
of a Vulnerable Adult.
Failure or omission of caregiver to provide
◦ care, goods, or services necessary to maintain the health or
safety of a vulnerable adult
Such as, failure to provide
food
clothing
medicine
shelter
supervision
medical services
May be repeated conduct or a single incident
Failure or omission has caused or presents a substantial
risk of causing physical or mental injury
SC Code Ann. § 43-35-10(6)
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Includes the inability of a vulnerable adult, in the
absence of a caretaker, to provide for his or her
own health or safety which produces or could
reasonably be expected to produce
◦ serious physical harm or
◦ psychological harm or
◦ substantial risk of death
SC Code Ann. § 43-35-10(6)
Noncompliance with regulatory standards alone
does not constitute neglect
SC Code Ann. § 43-35-10 (6)
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Law Enforcement was called to a Residential Care
Facility where they found an incoherent resident lying
in dirty bed linens with the smell of rotting skin.
EMS was contacted and they discovered that the
resident had stage IV decubitus ulcers filled with
maggots, was dehydrated, malnourished and near
death.
The resident was transported to the hospital where
death occurred.
The owner of the Residential Care Facility was
charged with Neglect of a Vulnerable Adult resulting in
death.
Incident must personally be reported within 24
hours orally by telephone or in writing
No facility can make policies that interfere with
reporting
A state agency may make a report on behalf of an
employee if policies have been approved by SLED
VAIU or other investigative entity
SC Code Ann. § 43-35-25(C)
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SLED Vulnerable Adults Investigation Unit (VAIU)
for incidents in facilities operated by or contracted
for operation by DMH or DDSN
Long Term Care Ombudsman of the Lieutenant
Governor’s Office for incidents in all other facilities
South Carolina Department of Social Services
Adult Protective Services for incidents in all other
settings
SC Code Ann. § 43-35-25(D)
Investigative entities insure that if report is made
to wrong agency it is forwarded to the proper
agency
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The death of any DMH client or DDSN consumer
must be reported to the SLED VAIU within 24
hours
The suspicious death of any vulnerable adult in
the community or any other facility setting must be
reported to the County Coroner or Medical
Examiner
SC Code Ann. § 43-35-35
Communications between attorney and client are
privileged
Communications between the following are not
excused from mandated reporting
◦ Husband and wife
◦ Professional person and patient or client
SC Code Ann. § 43-35-50
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A report made in good faith
◦ Is immune from civil and criminal liability
◦ good faith is a rebuttable presumption in civil and criminal
proceedings
SC Code Ann. § 43-35-75
It is against the public policy of South Carolina
to change an employee's status solely because
◦ the employee reports or
◦ the employee cooperates with an investigation under
OAPA
SC Code Ann. § 43-35-75
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to Report 43-35-85 (A)
Mandatory reporter knowingly and willfully fails to
report abuse, neglect or exploitation
If convicted they are guilty of a misdemeanor
Fined not more than $2500
Imprisoned not more than one year
SC Code Ann. § 43-35-85(A)
South Carolina Long Term Care Ombudsman
http://aging.sc.gov/Pages/default.aspx
South Carolina Department of Social Services
Adult Protective Services
South Carolina Law Enforcement Division (SLED)
http://www.sled.sc.gov/Vulnerable.aspx?MenuID=Vu
lAdult
17
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Your role is very important to the safety
and care of others.
Thank you for caring about South Carolina’s
vulnerable adults!
SC Adult Protection Coordinating Council
January 2014
18
DDSN Training for Abuse, Neglect and Exploitation
Comprehension Test
Employee Name:
Date of Test:
Date of training:
Score: __________(Must score 80% or re-test)
Provider Agency:
Section 1- True or False
1.
All reports of abuse, neglect or exploitation must be reported as soon as
possible, but within 24 hours.
2.
A resident of any DDSN facility is a Vulnerable Adult.
3.
Punishing a vulnerable adult by using a restrictive or physically intrusive
procedure to control behavior may be considered physical abuse unless the
procedure is included as a part of a therapeutic plan developed by a qualified
professional.
4.
5.
6.
Failure to properly follow a behavior support plan may result in an allegation of
abuse.
If an employee does not think an allegation of abuse is true, they do not have to
report.
An employee terminated for abuse, neglect, or exploitation as determined by
SLED, local law enforcement, the Attorney General’s Office, or DSS (either
APS or CPS) will not be eligible for employment in any program, facility,
service, or supports operated by DDSN or its contract service providers.
534-02-DD (NEW)
Page 1
True
False
True
False
True
False
True
False
True
False
True
False
Section 2- Multiple Choice
7.
The following persons are mandated reporters and shall report when they believe that a
vulnerable adult has been or is likely to be abused, neglected, or exploited:
A)
B)
C)
D)
8.
Employees and volunteers of DDSN and its network of contracted service providers are
all mandated reporters and are required to report the following in accordance with agency
policy and state law:
A)
B)
C)
D)
9.
Abuse
Neglect
Exploitation
All of the above.
The following action must take place when an alleged perpetrator has been identified:
A)
B)
C)
D)
10.
Medical Professionals (physician, nurse, dentist, etc…)
Teacher, Counselor, psychologist
Caregiver, staff, supervisors and volunteers of day and residential facilities
All of the above.
The staff is assigned to work with another consumer or in another location.
The staff receives a written warning and placed back on the schedule.
The staff must be placed on administrative leave without pay pending the
outcome of the investigation.
The staff is terminated without any internal review.
If under an Administrative or Management Review, the employee has been found to
violate Written Rules, Regulations or Policies, employee disciplinary action will be taken
based upon the nature and extent of the policy violation. This disciplinary action may
include:
A)
B)
C)
D)
Written Warning
Additional training
Termination
Any of the above, depending on the nature of the violation.
534-02-DD (NEW)
Page 2
Section 3- Please fill in the blank using the word list below
Child Protection Reform Act
Exploitation
Medicaid Fraud Control Unit (MFCU)
Supervisor
Omnibus Adult Protection Act
Long Term Care Ombudsman (LTCO)
Misdemeanor
Psychological Abuse
Department of Social Services (DSS)
Law Enforcement
11.
requires the reporting of any suspected
abuse or neglect occurring to a child, age 17 and under.
12.
requires the reporting of suspected abuse,
neglect, or exploitation of a vulnerable adult, age 18 and above.
13.
may include threatening, harassing or
intimidating a vulnerable adult or committing other acts of intimidation that cause fear,
humiliation, degradation, agitation, confusion, or other forms of serious emotional
distress.
14.
may include causing a vulnerable adult to
purchase goods or services for the profit or advantage of the seller or another person.
15.
investigates or cause to be investigated
noncriminal reports of alleged abuse, neglect, and exploitation of vulnerable adults
occurring in facilities other than those handled by SLED.
16.
The Adult Protective Services Program (APS) or Child Protective Services Program
(CPS) of the
investigates or causes to be
investigated noncriminal reports of alleged abuse, neglect, and exploitation of vulnerable
adults occurring in all settings other than facilities.
17.
The
of the Office of the Attorney General (AG)
investigates abuse, neglect and exploitation in facilities receiving Medicaid funds. This
entity also investigates and prosecutes health care fraud committed by Medicaid
providers.
18.
A mandated reporter who knowingly and wilfully fails to report is guilty of a
and, upon conviction, must be fined not more than twentyfive hundred dollars or imprisoned not more than one year.
19.
Provided the mandatory reporting requirements are met, a reporter can also make direct
contact with
, and in cases of an emergency,
serious injury, or suspected sexual assault law enforcement must be contacted
immediately.
20.
After the report to the appropriate investigative agency is made, the employee is
obligated to report the suspected abuse, neglect, or exploitation to their
or the Facility Administrator/Executive Director/CEO immediately
following the report to the appropriate state investigative agency. Immediately means
within one (1) hour. The person making the report must assure the alleged victim is safe.
534-02-DD (NEW)
Page 3
I have completed this Comprehension Test independently after receiving training on Abuse,
Neglect and Exploitation and DDSN Directive 534-02-DD: Procedures for Preventing and
Reporting Abuse, Neglect, or Exploitation of People Receiving Services from DDSN or a
Contract Provider Organization.
Date:
Employee Signature
Training staff responsible for providing correction for any missed questions to ensure the
employee understands the correct procedures:
Date:
Training Staff/ Supervisor Signature
534-02-DD (NEW)
Page 4