UPDATE: Revised Caregiver Misconduct Reporting
Requirements For Entities Regulated by the Bureau of Quality Assurance
PDF Version of BQA 04-028 (PDF
Date: November 22, 2004 -- DDES-BQA 04-028
Supersedes BQA 99-064, BQA 00-071
FROM: Jane Walters, Interim Director, Office of
Via: Criselda Ros-Dukler, Director, Bureau of Quality Assurance
BQA established consistent requirements that apply to all entities
covered under the Caregiver Law to conduct thorough internal
investigations and report allegations of caregiver misconduct and injuries
of unknown source. These requirements are fully outlined in the Wisconsin
Caregiver Program Manual found at http://www.dhs.wisconsin.gov/caregiver/publications/CgvrProgMan.htm.
Entities should refer to the Caregiver Program Manual for all Caregiver
Law questions, including background checks and reporting requirements.
To respond to current concerns and ensure entities understand their
responsibility to report allegations of caregiver misconduct, this memo
reviews and clarifies the requirements outlined in BQA Memo 99-064 and
reviewed in BQA Memo 00-071. This memo is issued to supersede these prior
memos and to direct you to reference Chapter 6 of the Wisconsin
Caregiver Program Manual for the detailed reporting requirements
This memo contains important clarification regarding:
Review of the Caregiver Misconduct Reporting Requirements
Entities are required to develop written procedures specifying:
- How and to whom staff are to report incidents;
- How internal investigations will be completed;
- How staff will be trained on the procedures related to allegations
of caregiver misconduct; and
- How residents will be informed of those procedures.
You must ensure that your employees, contractors, volunteers, clients
and nonclient residents are knowledgeable about your entity’s misconduct
reporting procedures and requirements. Your staff must be trained to immediately
report to the appropriate person all allegations of misconduct,
including abuse or neglect of a client or misappropriation of a client’s
Note: FDDs should refer to BQA Memo
04-002 regarding reporting allegations to the Administrator.
Immediately upon learning of an incident, you must take the
necessary steps to protect clients from possible subsequent
incidents of misconduct or injury. In addition to BQA reporting
requirements, you are encouraged to notify local law enforcement
authorities of any situation where there is a potential criminal offense.
As an entity regulated by BQA, you must immediately conduct a thorough internal
investigation of all allegations or incidents and document the
findings for each allegation or incident. A thorough internal
investigation may include:
- Collecting and preserving physical and documentary evidence;
- Interviewing alleged victims and witnesses;
- Collecting other corroborating/disproving evidence;
- Involving other regulatory authorities who can assist (e.g., local
law enforcement, elder abuse agency, Adult Protective Service agency);
- Documenting each step taken during the internal investigation.
Your entity should take these steps as part of your initial attempt to
determine what, if anything, happened, and to determine the complete
factual circumstances surrounding the alleged incident. Your entity’s
internal investigation will assist in determining if you must report an
incident to BQA. If you report the incident to BQA, your entity’s
internal investigation becomes part of the BQA caregiver misconduct
Reporting Decision Tools
The attached documents can help you determine if an incident must be
reported to BQA:
Incidents MUST be reported to BQA when:
- You have reasonable cause to believe you have sufficient information
or evidence or another agency could obtain the evidence, to show the
alleged incident occurred, and
- You have reasonable cause to believe the incident meets, or could
meet, the definition of abuse, neglect or misappropriation.
Caregiver Misconduct Definitions
See these references for the complete definitions of abuse, neglect and
Injury of Unknown Source
The definition of injury of unknown source has been revised to the
following federal definition:
- The source of the injury was not observed by any person or the
source of the injury can not be explained by the resident; and,
- The injury is suspicious because of the extent of the injury or the
location of the injury (e.g., the injury is located in an area not
generally vulnerable to trauma).
Refer to Chapter 6 of the Manual for case examples and investigation
Updated Incident Report of Caregiver Misconduct (DDE-2447)
If you conclude that you must report the incident to BQA, complete the Incident
Report of Caregiver Misconduct form, DDE-2447 (previously DSL-2447).
The Incident Report form has been revised to include more detailed
instructions to assist you in completing the report. Please discard
previous versions of the form, use the revised 10/04 version and follow
these steps to report an incident to BQA:
- Thoroughly complete the Incident
Report of Caregiver Misconduct form (DDE-2447) and attach relevant
internal investigation documents.
- Ensure the completed Incident Report is submitted according to the
- For allegations involving all staff (noncredentialed and credentialed),
submit the Incident Report to BQA at:
Department of Health & Family Services
Division of Quality Assurance
Office of Caregiver Quality
P. O. Box 2969
Madison, WI 53701-2969
Note: In the past, you were required to submit the report either to BQA or
to DRL. This process has been streamlined to eliminate reporting to two
different agencies. All caregiver misconduct reports are submitted to BQA, who
will forward reports involving credentialed staff (Doctors, RNs, LPNs, Social
Workers, etc.) to the Department of Regulation & Licensing (DRL) for
Entity Reporting Requirement Sanctions
An entity may be sanctioned for failing to meet caregiver misconduct
reporting requirements if the entity fails to take the following actions:
- Maintain written policies and procedures regarding caregiver misconduct,
including internal reporting requirements;
- Train all staff on those written policies and procedures;
- Immediately takes steps to protect the client(s);
- Begin its internal investigation immediately upon learning of an
- Conduct a thorough internal investigation and documents the results; and
- Make good-faith decisions in determining whether or not to report an
Entities must maintain the results of the 30 most recent internal
investigations that were not forwarded to BQA. Upon reviewing the results of
unreported incidents, BQA survey staff may still refer the allegations to the
Office of Caregiver Quality (OCQ) for possible investigation.
BQA’s Response to Incident Reports
BQA responds to two types of health care complaints:
- Complaints regarding entity activity (inappropriate or inadequate
activity by an entity).
- Complaints of caregiver misconduct (inappropriate activity by a
caregiver, e.g., abuse, neglect or misappropriation).
When BQA receives a complaint of caregiver misconduct from an entity or
another source, the report is screened by BQA’s Office of Caregiver Quality
(OCQ) to determine whether further investigation is warranted. Investigation
screening decisions are made on a case-by-case basis. OCQ notifies the accused
person, entity, staffing agency (if applicable) and complainant by letter
whether an investigation will be conducted by OCQ.
BQA may conduct a caregiver misconduct investigation by conducting on-site
visits, in-person interviews or telephone interviews. Both state investigators
and contracted private investigators complete caregiver misconduct
investigations. Not all reported incidents are investigated by BQA. However,
BQA does track and monitor all incident reports. When BQA observes a pattern
of reported incidents involving a caregiver, an investigation may be opened at
a later date.
In order for the Department to substantiate a finding of misconduct against
a caregiver, the incident must meet the definition of caregiver abuse, neglect
or misappropriation. After completing a caregiver misconduct investigation,
BQA determines whether there is sufficient evidence to substantiate the
complaint. An incident may violate the work rules or procedures of a facility
but at the same time, not meet the definitions or the evidentiary standards of
HFS ch. 13. Therefore, it is possible an employer may appropriately discipline
or terminate a caregiver for a particular incident, but BQA may determine the
incident does not constitute caregiver misconduct.
The entity’s BQA regulatory program (Assisted Living Section, Health
Services Section or Resident Care Review Section) may also conduct a parallel
investigation regarding the incident, to determine if the entity’s program
requirements were met and if the entity bears culpability regarding the
Wisconsin Caregiver Misconduct Registry
The Wisconsin Caregiver Misconduct Registry is a record of the names of
nurse aides and other noncredentialed caregivers with a substantiated finding
of caregiver misconduct. BQA discontinued the routine issuance of monthly
paper reports effective May 2001.
Entities should review on a monthly basis the caregivers whose names who
have been most recently added to the Wisconsin Caregiver Misconduct Registry
due to a substantiated finding. Some individuals who upon hire did not have a
finding, may receive one while employed but failed to report the finding to
the employing entity. Accordingly, the only way to know such findings is to
check the updated Misconduct Registry each month.
These monthly additions of caregivers with a finding of misconduct on the
Wisconsin Caregiver Misconduct Registry are posted by the 15th of
the month and may be viewed on the Internet at:
Federal regulations require that nurse aides with a finding of caregiver
misconduct be permanently barred from working in any capacity in federally
regulated nursing homes and intermediate care facilities for persons with
mental retardation (ICFs/MR). The Caregiver Misconduct Registry identifies
each caregiver by name, date of birth and type of caregiver.
More detailed information is available at Wisconsin’s Internet-based
Nurse Aide Registry at Pearson
Click on "Registry Services," then on "Wisconsin Nurse
Aides" and "Search the Nurse Aide Registry."
- For a nurse aide (NA): Information will be provided regarding the
aide’s employment eligibility and whether a finding of misconduct has
been placed under the aide’s name.
- For any other noncredentialed caregiver (CGE): Due to Wisconsin
state regulations, an individual, such as a personal care worker,
maintenance worker, laundry aide, etc., is identified as a caregiver (CGE)
with a finding on the Caregiver Misconduct Registry and may not be
employed as a caregiver as that term is defined in s. 50.065 or 48.685,
Wisconsin Stats., in any entity regulated by the Wisconsin DHS unless
approved through the Rehabilitation Review process.
BQA has issued numerous memos since 1998 regarding the Wisconsin Caregiver
Law. Rather than referring to previous memos, please reference the Wisconsin
Caregiver Program Manual at http://www.dhs.wisconsin.gov/caregiver/publications/CgvrProgMan.htm
for complete information regarding the Caregiver Law. The Manual provides
detailed information about the Caregiver Law, including background checks and
reporting requirements for Bureau of Quality Assurance (BQA) regulated
entities, and is updated annually.
You may also contact the Office of Caregiver Quality (OCQ) at DHSCaregiverIntake@wisconsin.gov
or (608) 243-2019 with questions.
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