ODP Certified Investigation Peer Review (CIPR) Manual

Transcription

1 2012 PROTECTING PEOPLE FROM HARM: EVALUATING THE QUALITY OF CERTIFIED INVESTIGATIONS ODP Certified Investigation Peer Review (CIPR) Manual This manual provides guidance on evaluating the quality of investigations through the Certified Investigator s Program managed by the Bureau of Supports for People with Intellectual Disabilities, Office of Developmental Programs, State of Pennsylvania. ODP is free to use these materials in perpetuity for the evaluation of certified investigations conducted throughout the ODP service delivery system. Dale J. Dangremond, BSW, MBA Dangremond Consulting, LLC in partnership with the Columbus Organization, Inc. through contract with the PA Department of Public Welfare, Office of Developmental Programs 3/1/2012

2 Table of Contents Introduction... 1 Part I: CIPR Standards and Evaluation Tools... 3 Investigation Files and the Certified Investigation Report... 4 Part II: Guidelines for Conducting the CIPR... 6 Structuring the CIPR Process... 6 Frequency of the CIPR... 7 How to Prepare and Conduct the CIPR Meeting... 7 Selecting Investigations for the CIPR... 8 Use of the Evaluation Findings... 9 Optional Oversight of the Investigation Process... 9 Oversight at the ODP Central Office Level Part III: The CIPR Tool and Related Forms Part IV: CIPR Users Guide General Guidelines CIPR Tool Section I: Initial Response to the Incident Report CIPR Tool Section II: Identification and Collection of Evidence CIPR Tool Section III: Certified Investigation Report (CIR) Appendix I: CIPR Tool and Supplemental Forms Appendix II: Sample Certified Investigation Report (CIR) Appendix III: Evidentiary Rules to Reconcile or Weigh Evidence Appendix IV: Stages of the Investigation Process CIPR Manual

3 INTRODUCTION As a result of the federal Medicaid Waiver and ICF/ID funds the State of Pennsylvania receives through the Centers for Medicare and Medicaid Services (CMS), the Office of Developmental Programs (ODP) is responsible for assuring to CMS that the basic health, safety, and welfare of individuals receiving services and supports through the ODP service delivery system occurs. The risk, incident, and quality management processes are some of the ways ODP works to provide assurances to CMS that the State of PA is striving to protect the health, safety and welfare of Medicaid recipients. One aspect of how these assurances are satisfied is through the requirements outlined in the Incident Management (IM) Bulletin # issued by ODP. The IM Bulletin requires identification, reporting and management of certain types of incidents involving harm, or the potential for harm, to people receiving services. One aspect of incident management is the requirement that Certified Investigators investigate critical incidents such as abuse, neglect, and other significant events identified in the IM Bulletin. In this respect, the data generated through an investigation helps improve decisions affecting the basic health, safety, and welfare of people receiving services and supports by organizations and the ODP service delivery system as a whole. It is also used to assure accuracy of the classification of incidents involving harm, or the potential for harm to people receiving services through the ODP service delivery system. Thus, the investigation process is an integral component of ODP s risk and incident management functions and is a key element of quality management activities. This manual and related evaluation tools reflect updated revisions to the Evaluating the Quality of Incident Investigations (or Peer Evaluation) process originally designed and implemented in conjunction with Labor Relations Alternatives, Inc. in While there are standards that have been revised, added, or deleted from the original documents, the basic structure of the review process and requirements remain consistent with requirements outlined in the IM Bulletin. Relationship to the IM and Certified Investigations Bulletins The IM Bulletin requires that service providers/entities develop and implement incident and risk management policy and procedures utilizing continuous quality improvement practices. The scope and complexity of service providers/entities throughout the ODP service delivery system varies widely. As a result, the design of incident and risk management practices should be tailored to the needs of the organization. PA ODP CIPR Manual V1.0 3/1/12 Page 1

4 ODP also issued the Certified Investigations Bulletin # (September 16, 2004) that outlines eligibility, initial training, and recertification requirements to become a CI. This Bulletin also includes the requirement that a CI wishing to be recertified at the end of the three (3) year certification cycle must: Complete three (3) certified investigations during a three (3)-year certification cycle; and Successfully complete the Recertification class. Note: If a CI wishes to continue to conduct certified investigations and has done fewer than three (3) investigations during the certification period, the CI must actively participate in the quarterly or semi-annual Certified Investigation Peer Review by serving as a member of a Peer Review committee or Risk Management committee. Participation means using the evaluation tools to review at least three (3) investigations and discussing the results with the committee. By applying the standards identified in the Certified Investigation Peer Review (CIPR) tool, valuable information is provided regarding the quality of certified investigations. This in turn supports the quality management and continuous quality improvement framework outlined in the IM Bulletin. This manual includes the following materials that are to be used in assessing the quality of certified investigations: 1. Standards identifying the requirements of a quality investigation; 2. Checklists used to measure the quality of investigations; and, 3. Instructions and interpretative guidelines regarding the process used when conducting CIPR reviews. PA ODP CIPR Manual V1.0 3/1/12 Page 2

5 Part I: CERTIFIED INVESTIGATION PEER REVIEW STANDARDS AND EVALUATION TOOLS The process of measuring the quality of investigations applies to those critical incidents requiring certified investigations as outlined in the ODP IM Bulletin (e.g. allegations of abuse, neglect, or mistreatment, deaths, serious injuries of unknown origin, etc.). The primary Certified Investigation Peer Review (CIPR) tool is intended to provide information about the quality of investigations through assessment of the following core areas: 1. Section I: Initial Response to the Incident Report 2. Section II: Identification and Collection of Evidence 3. Section III: Certified Investigation Report Peer reviewers use three (3) forms to collect the information that supports completion of the CIPR Tool: 1. CIPR Form 1: Physical and Demonstrative Evidence 2. CIPR Form 2: Witness Testimony and Written Statements 3. CIPR Form 3: Other Documentary Evidence In the context of continuous quality improvement, the CIPR becomes core in assessing the quality of the investigation process and incident management practices within an organization or system. In its most fundamental use, the CIPR is an indicator in assessing the quality of investigations from a peer or supervisory perspective and thus, provides performance feedback directly to the CI. Certified Investigators (CIs) are the primary users of the Certified Investigation Peer Review. The evaluation tools are designed to provide specific standards to guide the CI in conducting a quality review of certified investigations. For administrators and managers responsible for assuring incidents and investigations are managed properly in organizations, the CIPR is used to obtain objective information about the overall quality of the investigation process in their organization. For oversight entities, the CIPR provides the ability to objectively assess the overall quality of investigations conducted by a service provider or within their own organization. It can also be used to assess the quality of investigations throughout a system as a whole, e.g. throughout a specific region or across the entire ODP service delivery system. PA ODP CIPR Manual V1.0 3/1/12 Page 3

6 Investigation Files and Certified Investigation Report (CIR) To complete the Certified Investigation Peer Review, the evaluator participating in the peer review process must review the entire investigation file, including the related evidence and Certified Investigation Report (CIR). The investigation file is the primary repository of evidence and information about how relevant evidence (physical, demonstrative, testimonial, and documentary) was identified, collected, and preserved before, during, and after the investigation was conducted. Because of the highly confidential nature of information contained in investigation files involving both individuals receiving services and employees, organizations should create internal policies and procedures regarding how evidence and related contents of the investigation file are organized and maintained. Issues such as maintaining files/evidence in a secure location with limited and controlled access is critical to meeting expectations related to the chain of custody rules of maintaining the integrity of evidence over time. Practices such as allowing CIs to maintain investigation files/evidence in their desk or a file cabinet in their office should be avoided. If an organization contracts with a CI who is not an employee of the organization, then explicit language should be included in any letters of agreement/contracts with that individual/entity that the investigation file and related evidence is the property of the organization responsible for conducting the investigation. In addition to the evidence the CI identifies and collects, an important document prepared at the conclusion of the investigation and maintained in the investigation file is the Certified Investigation Report (CIR). While ODP currently does not mandate a standardized format for preparing the CIR, ODP strongly recommends that organizations utilize the Certified Investigation Report (CIR) when conducting investigations. A sample CIR format can be found in Appendix II of this manual and in the Pennsylvania ODP Certified Investigators Manual. The CIR provides a clear and comprehensive road map for executive management of an organization about the protocols used by the CI to identify, collect, and preserve evidence during an investigation. It also provides a summary of the evidence available to answer the primary investigatory question(s), and an analysis of potential issues that need to be considered when reconciling evidence and determining final conclusions. Ultimately, executive management in an organization is responsible and accountable for assuring the quality of investigations, and that proper decisions are made regarding the final conclusions and outcomes of the process including: PA ODP CIPR Manual V1.0 3/1/12 Page 4

7 Determining the preponderance of evidence (e.g. confirmed, not confirmed, inconclusive); and, Determining the related corrective actions (program, fiscal, personnel, administrative) that must be implemented. For entities with oversight authority (e.g. ODP, A/Es, the Department of Health, or others with responsibility and/or authority to review an investigation), the CIR provides a comprehensive picture of the protocols used to manage the critical incident from the time it was initially reported to its final conclusion, including implementation of corrective and preventive actions by the service provider. PA ODP CIPR Manual V1.0 3/1/12 Page 5

8 Part II: GUIDELINES FOR CONDUCTING CERTIFIED INVESTIGATION PEER REVIEWS The process adopted by organizations for conducting the CIPR should address the following areas: 1. Structuring the CIPR Process Given the scope and complexity of organizations, several alternatives exist as to how the CIPR process should be structured, including who should participate. The CIPR can be structured as follows: Service Providers 1 : a. Through an existing Safety or Incident Management/Risk Management committee. b. By establishing a new Peer Review committee. New committees should include a minimum of three (3) individuals. When possible, membership should be rotated. This allows for the continuing education of participants through the hands-on review process. c. Members of a CIPR committee should have completed either the Certified Investigator or the Evaluating the Quality of Certified Investigations course offered by ODP, although current certification would not be required to participate in the CIPR evaluation process. d. In the case of small provider organizations, the CIPR process can be approached by using a true peer-review model consisting of CIs in an organization reviewing each other s investigations. Administrative Entities (AEs) and ODP: a. The AE or ODP Regional Office Risk Management Committee conducts CIPRs of AE or ODP investigations. The review committee should be comprised of a minimum of three (3) members. b. If the AE or ODP Regional Office has a large Risk Management Committee, a CIPR subcommittee may be created to allow for a more manageable review process. 1 For the CIPR evaluation requirements, the State Operated Facilities (State Centers) and entities providing Supports Coordination services (SCOs) are considered service providers. PA ODP CIPR Manual V1.0 3/1/12 Page 6

9 c. If the AE or ODP Regional Office Risk Management Committee includes external stakeholders (e.g. service provider organizations, consumers, or other groups within the ODP service delivery system), members should be asked to sign a confidentiality agreement with the understanding that the information contained in the investigative files is to be used only for the CIPR review. 2. Frequency of CIPRs Service Providers: a. Service Providers should conduct CIPRs at least quarterly. b. An organization may decide to conduct CIPRs more frequently than the minimum standard. This is an agency policy decision that should be based on the scope and complexity of the organization s incident and risk management program. c. CIPR s can also be used to provide ongoing performance feedback to CIs. Administrative Entities (AEs) and ODP: a. AEs and ODP Regional Offices should conduct CIPR s at least semi-annually. b. More frequent CIPRs may occur based on an organization s current standard operating procedures (SOPs) and incident and risk management structures. c. CIPRs can also be used to provide ongoing performance feedback to CIs. 3. How To Prepare For and Conduct the CIPR Meeting Regardless of whether it is a Service Provider, AE, or ODP Regional Office, committee participants can conduct CIPRs in several different ways. Establish consistent CIPR standards by selecting one of the procedures below: Divide the selected cases between committee members; or, Have each member of the committee review every case selected. This can be helpful in establishing inter-rater reliability with new committees, or when adding new members to a committee. If using this method, committee members should review and rate the cases independently. After completing this task, the committee members meet to discuss their individual reviews and resolve any differences with individual scoring. PA ODP CIPR Manual V1.0 3/1/12 Page 7

10 Conduct CIPR Committee meetings as follows: a. The committee meeting should consist of a discussion of the CIPR findings for each case sampled. If there is discrepancy or disagreement among members on any item, consensus should be reached. b. Committee members should not evaluate their own cases. c. To expedite the meeting process, committee members should review/evaluate assigned cases prior to the CIPR meeting. 4. Selecting Investigations for the CIPR The number of investigations subject to CIPR is flexible based on the needs of the organization. The number of investigations selected for CIPR should be proportionate to the number of investigations completed annually and the number of certified investigators within an organization, but should be no less than ten percent (10%) of the investigations conducted during the review period. For example, if an organization sets the goal of improving the timeliness of investigations, reviewers may choose to examine fifty percent (50%) or even all of the investigations conducted during the review period. Organizations should consider these factors when selecting investigations for review: a. Select at least one (1) investigation conducted by each CI during the review period. This provides an opportunity for each CI to receive constructive, objective feedback on the quality of the investigation process and content of the CIR. This also provides feedback supporting the CI s focus on his/her own skill/knowledge areas needing improvement. b. Include investigations that were problematic, challenging, or complicated to complete to allow the CI(s) and organization the opportunity to learn from those experiences. c. Include inconclusive investigations to examine what factors contributed to that determination. d. Select investigations from various categories of incidents. e. If there were no investigations conducted during the current review period, then select cases from previous review periods that were not previously reviewed. PA ODP CIPR Manual V1.0 3/1/12 Page 8

11 5. Use of the Evaluation Findings Findings from the CIPR evaluation can be used in several different ways: a. The CIPR is designed as a learning resource for CIs to assist with improving the quality of investigations they complete. A copy of the CIPR evaluation should be provided to the CI at the completion of the review process. b. Compile and maintain findings annually from the CIPR evaluation process. Information from these aggregate reports can be used to identify systemic challenges within an organization and help improve quality initiatives, e.g. resource allocation, training, development of policies and procedures, etc. within an organization. Organizations can develop internal processes for sharing and acting on peer review findings. 6. Optional Oversight of the Investigation Process The optional oversight of the certified investigation process will be the responsibility of the AE, ODP Regional offices, and Central Office. This responsibility may include: Monitoring and providing guidance to Service Providers, AEs, and Regions as needed in conducting certified investigations; Evaluating the quality of those investigations; and, Identifying issues and concerns at the individual CI and systemic levels by using information from the CIPR process to improve the quality of the investigations through evaluation and oversight. The guidelines identified below are to be followed by the AE, and the ODP Regional or Central Offices when implementing the optional oversight process: a. Oversight reviews will occur at the discretion of the AE or ODP Regional or Central offices; b. The entity conducting the optional oversight process will have the option to review a selection of investigations conducted within their county or region. For example: If the AE implements the optional process the selection of investigations chosen for review would come from service providers within the county conducting investigations during the review period. If the ODP Regional Office implements the optional process the selection of investigations chosen would come from service providers and/or the AEs within the region who conducted investigations during the review period. PA ODP CIPR Manual V1.0 3/1/12 Page 9

12 If ODP Central Office implements the optional process the selection of investigations chosen would come from the ODP Regional Offices, AEs, or service providers throughout the state conducting investigations during the review period. c. If implementing the oversight review process the same committee reviewing investigations conducted by the AE or ODP Regional Office will be utilized. (See Part II.1. above related to AE and ODP Regional Office committee guidelines.); d. In large counties, drawing a sample to ensure each CI is represented may be prohibitive. In this case the sample may be drawn from service providers that had an incident investigation during the review period; e. In counties with many service providers, it may also be prohibitive to sample all agencies during one (1) review period. In this situation, evaluating an investigation from each service provider may be done over two (2) or more review periods; and, f. When the optional oversight process is implemented, feedback regarding the results of the review will be provided as follows: If the AE conducts optional oversight reviews, the AE will provide feedback to the service provider agencies evaluated. If the ODP Regional Office conducts the optional oversight review, the regions will provide feedback to the AE and/or service provider agencies evaluated. If ODP Central Office conducts optional oversight reviews, Central Office will provide feedback to the ODP Regional Office, AE and/or service provider agencies evaluated. 7. Oversight at the ODP Central Office Level ODP will contract with the vendor of the Certified Investigator Training Program to provide an external oversight evaluation of certified investigations conducted by, and/or evaluated using the CIPR process at the Service Provider, AE, and ODP Regional Office levels. The goal of oversight is two-fold: a. The vendor will review CIPRs completed by the entity (Service Provider, AE, and ODP) to evaluate and provide feedback on the entity s internal implementation and use of the CIPR process; and, b. The vendor will conduct independent CIPRs on completed investigations to evaluate and provide feedback on the quality of investigations conducted by that entity. PA ODP CIPR Manual V1.0 3/1/12 Page 10

13 Based on this review, the vendor will provide an objective report to ODP and the entity evaluated regarding the quality of the investigations conducted throughout the service delivery system and the extent to which the entity follows the CIPR evaluation procedures. III. THE CERTIFIED INVESTIGATION PEER REVIEW TOOL AND RELATED FORMS The following are the documents that are to be used when conducting CIPR evaluations: CIPR Evaluation Tool: This is the primary tool used to assess the core standards of quality investigations and is the form the CI or evaluator uses to record their findings after reviewing the investigation case file. The tool assesses three (3) core areas of the investigation process: Section I: Initial Response to Incident Report Section II: Identification and Collection of Evidence Section III: Certified Investigation Report. In order to complete Section II: Identification and Collection of Evidence, the following worksheets are to be completed prior to answering the related questions in Section II of the CIPR Evaluation Tool: CIPR Form #1: Physical and Demonstrative Evidence is used to complete Section II.A. of the CIPR tool. CIPR Form #2: Testimony and Witness Statements is used to complete Section II.B. and part of II.C. of the CIPR tool. CIPR Form #3: Other Documentary Evidence is used to complete Section II.C. of the CIPR tool. The CIPR Evaluation Tool and CIPR Forms 1-3 are found in Appendix I of this manual. For reference when conducting the CIPR evaluations, this manual also contains the following: Appendix II: Certified Investigation Report (CIR) form; Appendix III: Evidentiary Rules Used to Reconcile or Weigh Evidence graphic; and, Appendix IV: Stages of the Investigation Process chart. PA ODP CIPR Manual V1.0 3/1/12 Page 11

14 IV. CERTIFIED INVESTIGATION PEER REVIEW TOOL USERS GUIDE The remainder of this manual focuses on providing step-by-step guidance and interpretive guidelines for reviewing investigation case files and completing the CIPR Evaluation Tool and related forms. A. General Guidelines The following are general guidelines that should be followed to conduct proper CIPRs: 1. In order to conduct successful and effective CIPRs, the person conducting the review should have experience and/or training in conducting certified investigations or managing the investigation process. Throughout the evaluation process, the evaluator must think of the evidence and information being reviewed in the what if context, e.g. if I was assigned this investigation, what is the relevant evidence that should be identified and collected for the investigation? 2. The entire investigation file (not just the CIR or HCSIS information) should be reviewed prior to completing this evaluation, including all relevant physical, demonstrative, testimonial, and documentary evidence identified and/or collected for the investigation. 3. Relevant evidence is defined as evidence (physical, demonstrative, testimonial, or documentary) that simply has the potential to describe or explain the event or incident being investigated. PA ODP CIPR Manual V1.0 3/1/12 Page 12

15 B. CIPR TOOL SECTION I: INITIAL RESPONSE TO INCIDENT REPORT The speed at which an investigation is initiated is one (1) of the three (3) most important values associated with competent investigatory process. Evidence may be lost or will decay if there are delays in collecting physical, demonstrative, testimonial or documentary evidence. This section of the CIPR evaluation process assesses basic concepts of speed as it relates to identifying and reporting the incident, assigning and initiating the investigation, and concluding the investigation (for ICF/ID programs). 1. Section I, Question #1: Was the investigation assigned within 24 hours? a. Before marking #1, note the date and time the administrator (or designee) received notification of this incident; this information can be found in the Certified Investigation Report (CIR) Section I.2. b. Compare the date and time that the administrator (or designee) received notification of the incident with the date and time that the investigator was assigned the investigation; this information can be found in the CIR, Section I.4. c. The coding on the CIPR Tool would be as follows: i. Mark Yes if the assignment was made without unnecessary delay and within 24 hours or less; ii. Mark No if the assignment was made more than 24 hours from the time of notification. Note if a compelling reason for the delay is narrated in the investigatory report (e.g., delay in initial reporting incident, severe weather closed agency operations, etc.). 2. Section I, Question #2: Was the investigation initiated in a timely manner (1 st witness statement taken within 24 hours of assignment)? In deciding at what point an investigation was initiated, it is important to utilize a measure that will be common among almost all investigations. The best evidence to measure for this purpose is the date and time the CI interviewed their first witness and prepared their written statement of that interview. Even if no other evidence were literally available in an investigation, the CI would always be able to interview the Reporter of the incident, thus making the date/time the first witness interview occurs the best source of data to use as the measure for initiating the investigation. a. Compare the date/time the CI was assigned the investigation (#1 above) with the date and time the CI conducted the first witness interview and collected their statement. PA ODP CIPR Manual V1.0 3/1/12 Page 13

16 i. Mark Yes if the first written statement was taken 24 hours (or less) after the investigation was assigned. ii. Mark No if the first written statement was taken more than 24 hours after the incident was assigned. Note if there was reasonable justification for the delay noted in the CIR. 3. Section I, Question #3: For ICF/ID programs, were the results of the investigation submitted to the facility administrator (or designee) within 5 working days? a. ICF/ID programs have specific requirements regarding the conclusion of an investigation under the federal 483 regulations that require the following: Results of all investigations must be reported to the administrator or designated representative or to other officials in accordance with State law within five working days of the incident. (Tag W156, CMS ICF/MR 483 Regulations) The best measure of when an investigation is completed is the date/time the findings of fact are determined, e.g. confirmed, unconfirmed, or inconclusive. This decision should be made only when it is felt all relevant physical, demonstrative, testimonial, and documentary evidence was identified, collected, and presented by the CI through the CIR. b. The coding on the CIPR Tool would be as follows: i. Mark Yes if the CI submitted the results of the investigation to the administrator (or designee) for ICF/ID programs within five (5) working days (or less) after the CI was initially assigned the investigation. ii. Mark No if the CI submitted the results of the investigation to the administrator (or designee) for ICF/ID programs more than five (5) working days after the CI was initially assigned the investigation. Note if there was reasonable justification for the delay noted in the CIR. PA ODP CIPR Manual V1.0 3/1/12 Page 14

17 C. CIPR TOOL SECTION II: IDENTIFICATION AND COLLECTION OF EVIDENCE The ability to conduct a thorough, quality investigation directly relates to the CI s ability to properly identify and collect all relevant physical, demonstrative, testimonial, and documentary evidence. Section II of the CIPR Tool focuses on evaluating the thoroughness of the investigation. CIPR Forms 1, 2, and 3 are used for completing this section of the CIPR Tool. Each form should be completed prior to answering the questions in Section II on the CIPR Tool. Further detail regarding this task is found in the area of evidence the form is used to evaluate. When evaluating for relevant physical, demonstrative, testimonial, and documentary evidence in the investigation, remember the following definitions: Physical Evidence: includes things themselves (e.g. injuries, weapons, etc.), the spatial relationship amongst things (movement, distance, barriers that impact a witness ability to see or hear things, etc.), as well as the absence of things that otherwise would have been present if a version of testimony is to be considered accurate. Based on testimony provided by witnesses, examples may include the absence of injury that otherwise should reasonably be present, the condition of the environment where the incident allegedly occurred (including movement and location of people and things the environment). Demonstrative Evidence: the means by which physical evidence is preserved, e.g. photographs of injuries, diagrams of the environment where the incident occurred, x-rays or CT scans assessing for internal injury, etc. Testimonial Evidence: information a witness shares through a formal interview with the investigator relating to observations they made over time relevant to the incident being investigated. The capacity for observation derives from the senses: what the witness saw, heard, tasted, felt, or smelled. Documentary Evidence: the means by which testimonial evidence is preserved, e.g. written statements prepared as a result of interviews with the investigator. Documentary evidence also includes business records of the organization, e.g. program and medical records of individuals receiving services, personnel records of employees, policies and procedures, meeting minutes, fiscal records, etc. PA ODP CIPR Manual V1.0 3/1/12 Page 15

18 1. Section II.A: Identification and Collection of Physical and Demonstrative Evidence The following guidelines should be followed when completing Form 1, Tables 1-3: a. Form 1 - Table 1 (Physical Evidence): i. List all relevant physical evidence available to the CI (regardless of whether it was properly secured) at time of incident. ii. The list should include not only physical evidence actually identified by the CI in the case file, but any relevant physical evidence you believe should have been identified but was overlooked by the CI. iii. For columns 2 and 3 in Table 1, use Yes, No, N/A to mark whether the physical evidence was identified and/or collected by the CI. iv. A common problem impacting the overall quality of an investigation is the CI s failure to properly identify and/or collect the physical evidence available. This problem will initially appear in the CIR, Section II of the report where the CI is asked to identify the physical evidence available. This section will often have N/A regarding physical evidence, or will list things like photograph of injury which should be listed under the section dealing with demonstrative evidence. For example, if an allegation represented a statement like: John bashed the back of my head against the cement brick wall and hit me with a broom the physical evidence would be the following: Injury to the back of alleged victim s head (or absence of injury if medical assessment was negative for internal/external injuries consistent with testimony) Cement brick wall where the incident allegedly occurred Broom identified by alleged victim that was in the storage closet in the kitchen. v. For physical evidence that normally would be considered unreasonable to collect e.g. the injury to the alleged victim s head or the cement brick wall, the item should still be listed in Section II of the CIR, and on the CIPR Form 1 - Table 1 as physical evidence. vi. Column 3 of Table 1 would be marked N/A to reflect the condition where it was unreasonable to collect and preserve this piece of physical evidence (e.g. the alleged victim s head where injury was identified). If demonstrative evidence was created (a photograph of the alleged victim s head), Form 1 - Table 2 should list Photograph of injury to back of alleged victim s head to reflect demonstrative evidence was created to preserve PA ODP CIPR Manual V1.0 3/1/12 Page 16

19 the condition of the physical evidence at the time of the investigation. Mark the Yes/No column as to whether the photograph was actually taken and identified as evidence in the investigation file. If a photo was taken, also indicate the date/time it was done. b. Form 1 - Table 2 (Demonstrative Evidence Photos & Videos): i. Identify and list all relevant photos and/or videos available to the CI (regardless of whether it was properly secured at the time of incident. ii. Your list should include not only photos and videos actually identified/collected by the CI in the case file, but any relevant photos and videos you believe should have been identified and collected but were overlooked by the CI. iii. Mark yes, no, or N/A in Columns 2 and 3 to note if photographs or videos used as demonstrative evidence were properly identified and/or collected by the CI. iv. Identify the date and time the photos and/or videos were taken in the Column 4. Use the Notes column to identify any concerns or issues with the photo and/or video evidence, e.g. whether appropriate identifying information was marked, clarity of images, etc. c. Form 1 - Table 3 (Demonstrative Evidence - Other): i. Identify and list all relevant demonstrative evidence available to the CI (regardless of whether it was properly secured at the time of incident. ii. Your list should include not only demonstrative evidence actually identified/collected by the CI in the case file, but any relevant demonstrative evidence you believe should have been identified and collected but was overlooked by the CI. iii. Mark yes, no, or N/A in Columns 2 and 3 to note if the demonstrative evidence was properly identified and/or collected by the CI. iv. Use the Notes column to identify any concerns or issues with the other demonstrative evidence, e.g. PA ODP CIPR Manual V1.0 3/1/12 Page 17

20 After evaluating evidence to complete Form 1, Tables 1-3 the evaluation questions in Section II.A on the CIPR Tool can be answered. The following guidelines are used to complete this section: 2. Section II.A. Question #1: Was the scene visited by the investigator? a. Review the CIR for the date/time the CI visited the alleged site of the incident to assess for physical and demonstrative evidence. i. Mark Yes if the CI visited the alleged scene within 24 hours or less of being assigned the investigation. ii. Mark No if the CI did not visit the alleged scene of the incident. 3. Section II.A. Question #2: Was all relevant physical evidence collected? (See Form 1, Table 1: Physical Evidence) a. After completing CIPR Form 1, Table 1, transfer your findings as follows: i. Mark Yes if all relevant physical evidence was identified and collected. ii. Mark No if the CI failed to identify and collect all relevant physical evidence. iii. Mark No if the CI identified but failed to collect all relevant physical evidence but provided reasonable justification as to why all identified physical evidence was not collected in the CIR. Note this in the Reviewer s Notes column. 4. Section II.A. Question #3: Were photographs taken of injuries (or the absence of injury)? (See Form 1, Table 2: Photos and Video) a. For question 3.a. on the CIPR Tool, note the date/time initial photos were taken of injuries (or the absence of) (Note: Immediately in 3.a. means initial photos were taken within 24 hours of incident being reported). b. For question 3.b. on the CIPR Tool, note the date/time follow-up photos of injuries (or absence of) were taken over 72 hours from the time the incident was reported documenting the progression of potential injury. c. After completing CIPR Form 1, Table 2 transfer your findings as follows: i. Mark Yes if photographs documenting potential injuries (or absence of) were taken within appropriate timeframes for both 3.a. and 3.b. ii. Mark No if photographs of injuries (or absence thereof) were not taken within the identified timeframes. iii. Mark No if photographs were taken outside of the identified timeframes and the CI provided reasonable explanation in Section II.B of the CIR as to why this occurred. Identify this in the Reviewer s Notes column. PA ODP CIPR Manual V1.0 3/1/12 Page 18

21 5. Section II.A. Question #4: Was all other relevant demonstrative evidence collected? (See Form 1, Table 3: Demonstrative Evidence Other) a. Complete the CIPR Form 1, Table 3. b. The coding on the CIPR Tool would be as follows: i. Mark Yes if the CI identified and/or collected all other relevant demonstrative evidence (e.g. diagrams, x-rays, CT scans, photos of the environment where the incident allegedly occurred, etc.). ii. Mark No if all other relevant demonstrative evidence was not properly identified and/or collected by the CI. iii. Mark No if the CI properly identified all relevant demonstrative evidence but unable to collect all relevant demonstrative evidence (and provided reasonable explanation in Section II.B of the CIR of this omission). 6. Section II.B. Identification and Collection of Testimonial Evidence CIPR Form 2, Table 1 is used for answering questions #1-3 in Section II.B.; Form 2, Table 1 should be completed before answering these questions. The following guidelines are used to complete Form 2, Table 1: a. After reviewing the case file, identify and list the names of witnesses who can provide relevant testimony for the investigation in column 1, Name of Witness. After listing the names of those individuals on Table 1, go back and correlate this list to the list of witnesses identified and interviewed by the CI during the investigation. Use column 2, Witness Role, to identify the role of the witness to the incident, e.g. was the witness the alleged victim, alleged target, witness with circumstantial or direct evidence, expert witness, etc. b. Review this list against the list of witnesses identified by the CI in the Section II.C. of the CIR. When comparing lists, note on Form 2 the following: i. Whether the CI conducted the interview in-person (e.g. the interview wasn t simply a phone interview and the CI is able to verify with certainty the identity of the person interviewed); ii. Date/time the witness interview occurred; and iii. Whether a written statement was prepared from that interview. If the CI identified a compelling reason for not creating a written statement or conducting the interview in person that the evaluator considers relevant and available, explain in the Notes column. c. After preparing Form 2, Table 1, answer questions II.B.1-3 on the CIPR Tool. PA ODP CIPR Manual V1.0 3/1/12 Page 19

22 7. Section II.B. Question #1: Were all witnesses properly identified? a. Mark Yes if the CI properly identified all witnesses who could provide relevant testimony regarding the alleged incident. b. Mark No if the CI did not properly identify all witnesses with relevant testimony. Identify in the Reviewer s Notes column if the CI properly identified all witnesses who could provide relevant testimony regarding the alleged incident but was unable to conduct interviews with one (1) or more of the identified witnesses, and provided reasonable explanation in Section II.C. of the CIR as to those circumstances. c. NOTE: If this question is answered No for witnesses not properly identified, the next questions on the CIPR too, #2-3 in Section II.B. and #1-3 in Section II.C. should be answered based on a sample of witness statements reviewed using Form 2, Table Section II.B. Question #2: Were interviews conducted in-person? a. Using the results from Form 2, Table 1, mark item II.B.2. on the CIPR tool, Yes if the CI conducted all relevant witness interviews in-person. b. Mark No if the CI did not properly identify all witnesses with relevant testimony and did not conduct in-person interviews with those individuals. c. If the CI provided a compelling reason as to why witness interviews were not conducted in-person, mark No and identify the reason in the Notes column of the CIPR Tool. 9. Section II.B. Question #3: Were all interviews completed within 10 days (or 5 working days for ICF/ID programs) of the investigation being assigned? a. Using the results from Form 2, Table 1, assess the date and time the first and last witness interviews occurred. If this was within the 10 day timeframe (or 5 working days for ICF/ID programs), mark this item Yes on the CIPR Tool. b. Mark No if one (1) or more witnesses on Form 2, Table 1 were not interviewed by the CI within the required timeframes. If an explanation for the delay is provided, indicate the reason in the Notes column of the CIPR Tool. 10. SECTION II.C: IDENTIFICATION AND COLLECTION OF DOCUMENTARY EVIDENCE Use CIPR Form 2, Tables 1 and 2 for answering questions #1-4 in Section II.C.; complete Form 2, Tables 1and 2 before answering the questions on the CIPR tool PA ODP CIPR Manual V1.0 3/1/12 Page 20

23 (Table 1 was completed above). The following guidelines are used to complete Form 2, Table 2: a. Form 2, Table 2 assesses the overall quality of the witness statements. These statements are used to preserve the testimony provided by the witness during the interview conducted by the CI. If the CI conducted a properly structured interview, the witness statement should reflect that process. The standards identified on CIPR Form 2, Table 2, reflect this structure. b. Between two (2) and eight (8) witness statements from the investigation should be selected for review. c. In the Witness Statements Reviewed column, use the smaller columns to identify the statements reviewed by putting the witnesses initials in each column. d. Review the selected statements against the standards identified in CIPR Form 2, Table 2. The standards on Table 2 are self-explanatory, with the exception of #4 and #5. Mark each standard Yes or No in the column correlating to the witness statement reviewed. e. #4 relates to the organization and flow of the statement. For example, is it chronologically sequenced? Is there a natural beginning, middle, and end flow to the statement that provides the reader a reasonable understanding of what happened from the witness perspective? i. Mark Yes if the statement is organized in a sequential manner and provides the evaluator a reasonable understanding of this witness observations. ii. Mark No if the statement is not organized and no other explanation exists as to why. iii. Mark No if the statement is not organized in a sequential manner, but the CI provided an explanation in the CIR as to why, e.g. due to cognitive limitations the witness was unable to provide information in a sequential manner. Reference this in the Reviewer s Notes column. iv. Mark No if the statement is not organized sequentially, but has information added at the end of the statement that clarifies the witness account of what happened, and does not confuse the evaluator s understanding of the witness overall knowledge. f. #5 relates to level of detail, or thoroughness, of the information generated by the CI during the interview and documented in the witness statement. The evaluator should be looking for the following when reviewing written statements: i. Sufficient detail regarding the witness involvement in the incident, and/or the basis of their knowledge. ii. Information regarding the witness knowledge of the who, what, where, when and how of the incident. PA ODP CIPR Manual V1.0 3/1/12 Page 21

24 iii. Sufficient detail regarding the use of follow-up questions by the CI to clarify statements made by the witness. iv. Identifying information of people, places, etc. is clearly detailed and documented. If a witness identifies any individual by name, it is appropriate and expected that those names (and titles/relationships if provided) be fully documented in the original statement. The statement should not contain initials, number identifiers, etc. when the witness has identified people by name. v. Mark this item Yes on CIPR Form 2, Table 2, if the CI has met the above standards in the witness statements evaluated. vi. Mark this item No if one (1) or more of the witness statements reviewed did not provide sufficient detail and the CI did not provide reasonable explanation as to those conditions. vii. Mark this item No if it appears the CI attempted to meet the above standards, but was unable to do so and provided reasonable explanation in the Section II.D.1 of the CIR, e.g. witness was uncooperative. Note this in the Reviewer s Notes column. 11. Section II.C. Question #1: Were written statements taken from all witnesses identified in II.B.1. above? a. Using the results from Form 2, Table 1, mark item II.C.1. on the CIPR Tool Yes if the CI prepared written statements within the required timeframes for all witnesses interviewed. b. Any statements provided by a witness without benefit of an interview and not done in the presence of the CI within the required timeframes should be marked No. c. If the CI provided a compelling reason as to the omission of a written statement that should otherwise be reasonably present, mark No and identify the omission in the Notes column of the CIPR Tool. Note: only statements obtained as the result of an interview by the CI can be marked Yes. 12. Section II.C. Question #2: Did witness statements reviewed satisfy quality standards based on results from Form 2, Table 2? a. Using the results from Form 2, Table 2, mark item II.C.2. on the CIPR Tool Yes if the written statements reviewed were Yes on Form 2, Table 2. b. Mark No if one (1) or more of the witness statements evaluated received a No on Form 2, Table 2. PA ODP CIPR Manual V1.0 3/1/12 Page 22

25 13. Section II.C. Question #3: Were all witness written statements listed in the CIR preserved in the investigation file? a. In assessing this standard, did the evaluator find evidence that witness statements* were properly preserved in the investigation file to maintain the chain-of-custody of this evidence? (*Statements include: hand written and/or typed statements on paper, as well as video or audio tapes of interviews that were created because of specialized interview circumstances, e.g. witness is deaf and a sign language interpreter was present during the interview.) b. Mark Yes if all witness statements were properly preserved in the investigation file. c. Mark No if one (1) or more witness statements were not properly preserved in the investigation file. Note any explanations for why the witness statements are not preserved in the investigation file. 14. Section II.C. Question #4: Was all other relevant documentary evidence (other than witness statements identified above) collected? (See CIPR Form 3 Other Documentary Evidence) a. CIPR Form 3: Other Documentary Evidence should be completed before answering question #4, Section II.C. on the CIPR Tool. CIPR Form 3 is used to assess the documentary evidence (other than witness statements) the CI identified and collected during the investigation; documentary evidence includes business records of the organization, e.g. case records, personnel and fiscal information of the organization, policies and procedures, etc. To complete CIPR Form 3, the following protocols should be followed: i. After reviewing the case file, identify and list the documentary evidence relevant to the investigation in column 1 (this is the documentary evidence the evaluator believes is relevant to the investigation). ii. Review the list in column 1 against the documentary evidence the CI actually identified and collected during the investigation. iii. Mark Yes if the documentary evidence was collected, and note the date of collection. iv. Mark this item No if the CI failed to identify and collect any documentary evidence that was relevant to the investigation. v. If documentary evidence was omitted by the CI, and a compelling reason is provided for the omission in the CIR, Section II.D., mark this item No with an explanation in the Notes column of CIPR Form 3. PA ODP CIPR Manual V1.0 3/1/12 Page 23

26 b. Compare the results from CIPR Form 2 and mark item II.C.4. Yes on the CIPR Tool if all relevant documentary evidence was collected. c. Mark this item No if the CI failed to properly identify and collect any relevant piece of documentary evidence and there is no reasonable explanation justifying the omission. d. If the CI provided a compelling reason as to why a piece of documentary evidence was not collected, mark No and identify the reason in the Notes column of the CIPR Tool. D. CIPR TOOL SECTION III: CERTIFIED INVESTIGATION REPORT (CIR) The Certified Investigation Report (CIR) is an important tool of the investigation process. Not only does it serve to clearly articulate the protocols used to identify, collect, and preserve evidence, it s also the means by which the CI presents and analyzes the evidence important to answering the investigatory questions. In this regard, the CIR is the foundation that supports not only the conclusions drawn from the evidence; it also helps create the plan of corrective action resulting from the conclusions. The corrective action plan can be used to establish proactive preventive measures to protect individuals from future harm and support quality improvement efforts for Risk/Incident Management. Section III of the CIPR Tool assesses the major elements of a quality investigation report. When investigation reports are not prepared utilizing a consistent format that organizes information clearly and concisely related to investigation protocols, the CI, management of organizations, and others responsible for reviewing this information are at much greater risk of reaching improper conclusions and recommendations for corrective action. A sample CIR is found in Appendix II of this manual. 1. Section III.A. Question #1: Is there a CIR prepared? (If no, identify how the evidence from the investigation was presented for review/decision-making in the Notes column.) a. Mark Yes if there is a CIR prepared. b. Mark No if there is no CIR prepared, or if the report is prepared in a format different from the CIR sample. 2. Section III.A. Question #2: Was the CIR written in the format presented in the CI course? a. Mark Yes if there is a CIR prepared that follows the format presented. b. Mark No if there is no CIR prepared, or if the report is prepared in a format different from the CIR sample. PA ODP CIPR Manual V1.0 3/1/12 Page 24

27 3. Section III.A. Question #3: Are the investigation protocols used to identify and collect testimonial, documentary, physical and demonstrative evidence accurately and concisely summarized? a. After reviewing the CIR, determine if the CI presented an accurate and concise presentation of the identification and collection of the relevant physical, demonstrative, testimonial, and documentary evidence. b. Mark Yes if Section II of the CIR presents the identification and collection of physical, demonstrative, testimonial, and documentary evidence following the format presented in the sample CIR and if the evidence collected by the CI is correctly presented. c. Mark No if Section II of the CIR does not follow the format presented in the sample CIR, or if the CI does not correctly present the evidence collected. 4. Section III.B. Summary and Analysis of Evidence This section of the report is used to document the following: a. Identifying the primary question(s) needing to be answered as a result of the investigation. If multiple questions are identified, they should be listed separately in the CIR, Section III, #1. The classifying and analyzing of the relevant evidence important to answering those questions should be identified and noted separately for each question as well. b. Classifying the direct and circumstantial evidence available to answer that question(s) (CIR Section III, #2 and 3). This is where the CI identifies the relevant direct and circumstantial evidence that becomes important to answering the question. c. Analyzing the evidence in relation to the rules of evidence used to reconcile or weigh the evidence in order to determine the preponderance of evidence that leads to the final conclusions or findings of fact of the investigation (CIR Section IV, #1). A graphic of the basic rules used to reconcile evidence is found in Appendix III of this manual to reference when answering the CIPR Tool Section III.B.3 and Section III.B. Question #1: Was the investigatory question clearly stated in Section III Evidence Summary section of the CIR? a. Mark Yes if the investigatory question reflects conditions related to the original incident report and was clearly and objectively stated. b. As a result of evidence collected during an investigation, additional investigatory questions may arise; each question should be independently addressed in PA ODP CIPR Manual V1.0 3/1/12 Page 25

28 Section III of the CIR. Mark Yes if additional investigatory questions were identified by the CI and addressed independent of the others in the report. c. Mark No if the investigatory question is stated in a way that might reflect bias and influence how evidence is evaluated. d. Mark No if the need for additional investigatory questions was identified during the review process, but not properly identified in Section III of the CIR. 6. Section III.B. Question #2: Is the direct and circumstantial evidence available properly identified and classified relevant to each investigatory question(s)? a. Review Section III of the CIR as it relates to the evidence identified and collected by the CI to properly evaluate this question. b. Mark Yes if the CI properly identified the direct and circumstantial evidence available to answer the investigatory question(s). c. Mark No if any direct or circumstantial evidence was improperly classified in Section III of the CIR. 7. Section III.B. Question #3: Is there a description of how the evidence was initially reconciled and analyzed by the CI (Section IV of the CIR)? Is the analysis drawn from the evidence and does not include speculation by the CI? When preparing investigation reports, the CI must not only summarize the available evidence and indicate their findings. In order to form a conclusion evidence must be properly reconciled and weighed, including assessing the credibility of witnesses. In evaluating this part of the investigation process, the reviewer must also be careful not to assess the CI s work in a negative manner simply because she or he does not agree with the analysis. Section IV of the CIR containing the analysis and findings should be reviewed to answer this question. a. Mark Yes if the CI provides information about how evidence was analyzed in reaching a finding. b. Mark No if there is no analysis of evidence. 8. Section III.B. Question #4: Is the initial conclusion(s) of evidence provided by the CI based on summary and analysis of evidence? Does it flow logically, and is it consistent with the Analysis of Evidence? a. Compare the findings the investigator reached with the summary of the evidence and its analysis. PA ODP CIPR Manual V1.0 3/1/12 Page 26

29 b. Mark Yes if the CI s summary of evidence and analysis support the findings. c. Mark No if the CI s if the summary of evidence and analysis does not support the findings. 9. Section III.C. Administrative Review, Findings, Recommendations, and Implementation This section of the CIPR Tool focuses on assessing how the investigation was reviewed and finalized by management (or designee) of the entity responsible for conducting the investigation, including recommendations made for corrective action, and whether implementation of those recommendations (or closing the loop ) has occurred. This section does not reflect or measure the quality of the investigation completed by the CI. 10. Section III.C. Question #1: Has the investigation been reviewed by management (or designee) of the entity responsible for conducting the investigation? The Incident Manager and Point Person of the entity responsible for conducting the investigation? a. Mark Yes if there is evidence the investigation has been reviewed by both Executive Management (or designee) of the organization, and the organization s Incident Manager and Point Person. b. Mark No if the investigation has not been reviewed by Executive Management (or designee), or by the Incident Manager and Point Person. 11. Section III.C. Question #2: Does the preponderance of the evidence support the final conclusion(s)? a. Mark Yes if the rules used to reconcile evidence were appropriately and objectively applied and that the preponderance of evidence rule was appropriately applied to support the conclusion. b. Mark No if the preponderance of evidence rule was not appropriately applied to the evidence to support the conclusion. PA ODP CIPR Manual V1.0 3/1/12 Page 27

30 12. Section III.C. Question #3: Does the conclusion(s) reflect that a violation of agency and/or ODP policy or regulation has occurred (as appropriate)? a. Mark Yes if the CI accurately identifies violations of agency and/or ODP policy or regulation in Section IV of the CIR. b. Mark No if violations of agency and/or ODP policy or regulation were not properly identified in Section IV of the CIR. c. Mark N/A if the conclusion(s) of the investigation are unfounded or inconclusive and no violation of agency and/or ODP policy or regulation occurred. 13. Section III.C. Question #4: Has the certified Investigator identified the cause of the incident, contributing factors or issues leading to the incident? Does the CIR discuss why the incident occurred? a. Mark Yes if Section IV or V of the CIR reflects information related to identifying why the incident occurred. b. Mark No if Section IV or V of the CIR does not reflect information related to identifying reasons why the incident occurred. 14. Section III.C. Question #5: Are activities and timelines for corrective action identified? a. Mark Yes if Section V of the CIR identified activities and timelines for corrective action based on the findings of the investigation. b. Mark No if Section V of the CIR does not identify activities and timelines for corrective action. 15. Section III.C. Question #6: Is there evidence in the investigation file that there was implementation of recommendations and corrective action requirements (includes preliminary corrective actions required at time of discovery and corrective actions required upon finalizing the investigation)? a. Mark Yes if there is evidence that both preliminary corrective actions were taken to assure the health and safety of individual(s), and corrective actions were identified upon finalizing the investigation. b. Mark No if no preliminary corrective actions were taken, or if corrective actions identified upon finalizing the investigation were inconsistent with the evidence. PA ODP CIPR Manual V1.0 3/1/12 Page 28

31 16. Section III.C. Question #7: Were preventive measures identified to mitigate future risk documented in the person s plan and implemented? a. Mark Yes if preventive measures were identified, documented in the person s plan, and evidence supports these measures were implemented. b. Mark Yes if preventive measures were identified and documented in the person s plan, and evidence supports implementation of these measures is underway. c. Mark No if preventive measures were not identified for the individual. d. Mark No if preventive measures were identified in the CIR but not in the person s plan. e. Mark No if preventive measures were identified in the person s plan and there is no evidence showing implementation of these measures is occurring. 17. Section III.C. Question #8: Was the following information finalized in HCSIS within 30 days of the incident being recognized or discovered: final determination of the investigation (e.g. confirmed, not confirmed, inconclusive); abuse or neglect founded/unfounded/both/neither ; and a summary of the CIR Section III and IV (Summary and Analysis of Evidence)? a. Mark Yes if all three (3) criteria identified above were entered into HCSIS and the summary Section III and IV of the CIR reflects 100% the information contained in the actual CIR. b. Mark No if one (1) or more of the required criteria was not entered into HCSIS. c. Mark No if all three (3) criteria were entered into HCSIS, but the summary of Section III and IV does not accurately reflect (less than 100%) the information contained in the actual CIR. 18. Section III.C. Question #9: Has the HCSIS Incident Report (including the certified investigation information) been reviewed within 30 days by the County A/E Incident Manager (or designee), and ODP Regional Incident Manager (or designee)? a. Mark Yes if the HCSIS Incident Report was reviewed within 30 days by the A/E Incident Manager (or designee) and the ODP Regional Incident Manager (or designee). b. Mark No if the HCSIS Incident Report was not reviewed within 30 days by both the A/E and ODP personnel. Identify in the Notes section the evidence used to support the No assessment. PA ODP CIPR Manual V1.0 3/1/12 Page 29

32 APPENDIX I: CIPR Tool and Supplemental Forms The following documents will be found in this section of the manual: 1. The CIPR Tool 2. CIPR Form #1: Physical and Demonstrative Evidence is used to complete Section II.A. of the CIPR Tool. 3. CIPR Form #2: Testimony and Witness Statements is used to complete Section II.B. and part of II.C. of the CIPR Tool. 4. CIPR Form #3: Other Documentary Evidence is used to complete Section II.C. of the CIPR Tool. These documents are to be printed and copied for use when completing CIPRs. PA ODP CIPR Manual V1.0 3/1/12 Page 30

33 State of Pennsylvania/Office of Developmental Programs (ODP) Certified Investigation Peer Review (CIPR) Tool HCSIS Incident #/Organization: Certified Investigator: Date of Evaluation: Evaluator s Name: ASSESSMENT QUESTION Yes No N/A REVIEWER S NOTES I. INITIAL RESPONSE TO INCIDENT REPORT 1. Was the investigation assigned within 24 hrs? Date/Time Incident occurred/discovered: Date/Time Incident Reported: Date/Time CI assigned: Name of CI: 2. Was the investigation initiated in a timely manner (1 st witness statement taken within 24 hrs of assignment)? Date/time of 1 st Witness interview: 3. For ICF/ID programs, were the results of the investigation submitted to the facility administrator (or designee) within 5 working days? Date results submitted to facility admin: II. IDENTIFICATION AND COLLECTION OF EVIDENCE A. IDENTIFICATION AND COLLECTION OF PHYSICAL AND DEMONSTRATIVE EVIDENCE 1. Was the scene visited by the CI? 2. Was all relevant physical evidence identified and collected (See Form 1, Table 1: Physical Evidence)? 3. Were photographs taken of injuries (or the absence of injury) (See Form 1, Table 2: Photos and Video): a. Immediately? Date/time of 1st photos: PA ODP CIPR Manual V1.0 3/1/12 Page 31

34 State of Pennsylvania/Office of Developmental Programs (ODP) Certified Investigation Peer Review (CIPR) Tool HCSIS Incident #/Organization: Certified Investigator: Date of Evaluation: Evaluator s Name: ASSESSMENT QUESTION Yes No N/A REVIEWER S NOTES b. Over the course of the first 72 hours after the initial incident report was received? Date/times of secondary photos? (If no photographs were taken, identify why in Notes ) 4. Was all other relevant demonstrative evidence identified and collected (See Form 1, Table 3: Demonstrative Evidence Other)? B. IDENTIFICATION AND COLLECTION OF TESTIMONIAL EVIDENCE (Note: CIPR Form #2 should be completed and used to answer the following questions) 1. Were all witnesses properly identified? 2. Were interviews conducted in-person? 3. Were all interviews completed within 10 days of the investigation being assigned? (Refer to I.1 above) Date/Time Last Witness Interview: C. IDENTIFICATION AND COLLECTION OF DOCUMENTARY EVIDENCE (Note: CIPR Form 2 and Form 3 should be completed and used to answer the following questions) 1. Were written statements taken from all witnesses identified in II.B.1. above? (See Form 2 Witness Statements) 2. Did witness statements reviewed satisfy quality standards based on results of Form 2, Table 2? PA ODP CIPR Manual V1.0 3/1/12 Page 32

35 State of Pennsylvania/Office of Developmental Programs (ODP) Certified Investigation Peer Review (CIPR) Tool HCSIS Incident #/Organization: Certified Investigator: Date of Evaluation: Evaluator s Name: ASSESSMENT QUESTION Yes No N/A REVIEWER S NOTES 3. Were all witness written statements listed in the CIR preserved in the investigation file? 4. Was all other relevant documentary evidence (other than witness statements identified above) identified and collected? (See Form 3 Other Documentary Evidence) III. CERTIFIED INVESTIGATION REPORT (CIR) A. INVESTIGATION PROTOCOLS 1. Is there a CIR prepared? (If no, identify how the evidence from the investigation was presented for review and decision-making in the Notes column) 2. Was the CIR written in the format presented in the CI course? 3. Are the investigation protocols used to identify and collect testimonial, documentary, physical and demonstrative evidence accurately and concisely summarized? (Section II of the CIR format) B. SUMMARY AND ANALYSIS OF EVIDENCE 1. Was the investigatory question clearly stated Section III. Evidence Summary section of the CIR? a. Is each investigatory question that needs to be answered identified separately? (Multiple violations, e.g. physical abuse, neglect, etc. must be stated separately) 2. Is the direct and circumstantial evidence available properly identified and classified relevant to each investigatory question(s)? PA ODP CIPR Manual V1.0 3/1/12 Page 33

36 State of Pennsylvania/Office of Developmental Programs (ODP) Certified Investigation Peer Review (CIPR) Tool HCSIS Incident #/Organization: Certified Investigator: Date of Evaluation: Evaluator s Name: ASSESSMENT QUESTION Yes No N/A REVIEWER S NOTES 3. Is there a description of how the evidence was initially reconciled and analyzed by the investigator? (Section IV of the CIR) a. Is the analysis drawn from the evidence and does not include speculation by the investigator? 4. Is the initial conclusion(s) of evidence provided by the CI based on summary and analysis of evidence? Does it flow logically, and is consistent with, the Analysis of Evidence? C. ADMINISTRATIVE REVIEW, FINDINGS, RECOMMENDATIONS, AND IMPLEMENTATION (Section V of the CIR) 1. Has the investigation been reviewed by the: a. Management (or designees) of the entity responsible for conducting the investigation? Signature(s)/Date of Review(s): b. Incident Manager and Point Person of the entity responsible for conducting the investigation? Signature/Date of Review: 2. Does the preponderance of the evidence support the final conclusions? 3. Does the conclusion(s) reflect that a violation of agency and/or ODP policy or regulation has occurred (as appropriate)? 4. Have cause of incident, contributing factors or issues leading to the incident been identified? Does it give a sense as to why the incident occurred? 5. Are activities and timelines for corrective action identified? PA ODP CIPR Manual V1.0 3/1/12 Page 34

37 State of Pennsylvania/Office of Developmental Programs (ODP) Certified Investigation Peer Review (CIPR) Tool HCSIS Incident #/Organization: Certified Investigator: Date of Evaluation: Evaluator s Name: ASSESSMENT QUESTION Yes No N/A REVIEWER S NOTES 6. Is there evidence in the investigation file that there was implementation of recommendations and corrective action requirements? a. Corrective Actions required at time of discovery? b. Corrective Actions required upon finalizing the investigation? 7. Were preventive measures identified to mitigate future risk and: a. Documented in the person s plan? b. Implemented? 8. Was the following information finalized in HCSIS within 30 days of the incident being identified or discovered? a. Final determination of the investigation (e.g. confirmed, not confirmed, inconclusive) b. Abuse or neglect founded/unfounded c. Summary of Investigation findings as was written in the CIR Section III and IV (Summary and Analysis of Evidence) 9. For County A/E and Regional ODP only, has the HCSIS Incident Report (including the certified investigation information) been reviewed within 30 days by the: a. County A/E Incident Manager (or designee) Signature/Date of Review: b. Regional Incident Manager (or designee)? Signature/Date of Review: PA ODP CIPR Manual V1.0 3/1/12 Page 35

38 CIPR FORM #1: PHYSICAL AND DEMONSTRATIVE EVIDENCE HCSIS Case #: CI Name: Date of Review: Evaluator Name: Table 1: Physical Evidence Relevant Physical Evidence Identified? (Y/N/NA) Collected? (Y/N/NA) NOTES Table 2: Demonstrative Evidence Photos & Video List Relevant Demonstrative Evidence Photos & Video Identified? (Y/N/NA) Collected? (Y/N/NA) Date/Time of Image NOTES PA ODP CIPR Manual V1.0 3/1/12 Page 36

39 CIPR FORM #1: PHYSICAL AND DEMONSTRATIVE EVIDENCE HCSIS Case #: CI Name: Date of Review: Evaluator Name: Table 3: Demonstrative Evidence - Other List Relevant Demonstrative Evidence Identified? (Y/N/NA) Collected? (Y/N/NA) NOTES PA ODP CIPR Manual V1.0 3/1/12 Page 37

40 CIPR FORM #2: WITNESS TESTIMONY AND WRITTEN STATEMENTS HCSIS Case #: CI Name: Date of Review: Evaluator Name: TABLE 1 WITNESS TESTIMONY Name of Witness Witness Role (e.g. Alleged Victim, Target, etc.) In Person Interview (Y/N) Date/Time of Interview Written Statement (Y/N) Notes PA ODP CIPR Manual V1.0 3/1/12 Page 38

41 CIPR FORM #2: WITNESS TESTIMONY AND WRITTEN STATEMENTS HCSIS Case #: CI Name: Date of Review: Evaluator Name: CIPR FORM 2 - TABLE 2: QUALITY OF WITNESS STATEMENTS CIPR Evaluation Question Witness Statements Reviewed (use initials to identify statements reviewed) Notes 1. Is the following information documented on the form: a. Case Name? b. Date/time/place of interview? 2. Is information identifying the witness properly documented including: a. Name? b. Contact information (address, phone #s, etc.)? c. Role, e.g. Alleged Victim, Alleged Target, in vicinity at time incident occurred, etc.? 3. Is the name of the CI conducting the interview identified on the statement? 4. Is the information provided by the witness chronologically sequenced? If no, explain. 5. Is there sufficient detail contained in the statement? If no, explain. 6. Was the statement written in ink? 7. Were all corrections, margin notes, etc. made on the statement initialed and dated by the witness? 8. Was the statement signed and dated by: a. The witness? b. The CI? c. Any 3 rd party present during any point of the interview? 9. If the statement was retyped was: a. The original statement attached to the typed document? b. Were both documents signed by the witness and CI (and any 3 rd party present)? PA ODP CIPR Manual V1.0 3/1/12 Page 39

42 CIPR FORM #3: OTHER DOCUMENTARY EVIDENCE HCSIS Case #: CI Name: Date of Review: Evaluator Name: TABLE 1: OTHER DOCUMENTARY EVIDENCE List Relevant Documentary Evidence Collected? (Y/N) Date Collected Notes PA ODP CIPR Manual V1.0 3/1/12 Page 40

43 Appendix II - Sample Certified Investigation Report Format CERTIFIED INVESTIGATION REPORT Case Name: Incident #: Certified Investigator: Date of Report: I. INTRODUCTORY STATEMENTS (Note: this section of the report is used to introduce basic information associated with how the incident was identified and reported, a brief description of the initial allegation, and to document initial decisions made regarding the need to conduct an investigation including assignment of the investigator.) The following information should be documented in this section: 1. If known, the date and time incident allegedly occurred. 2. The date and time incident was reported to agency personnel. 3. The name(s) of the person(s) reporting the incident and their role or relationship to the principals involved in the incident. 4. The date and time investigator was assigned the case (note any possible conflicts of interest identified when assigning the investigation). 5. A description of the allegation and information provided to the CI at the time of assignment. II. INVESTIGATION PROTOCOLS (Note: the following section is used to document the investigative protocols utilized to identify, collect, preserve, and analyze evidence available to the investigation. When possible, simply use lists to present the information rather than longer, narrative formats of writing.) A. General Introduction The following information should be documented in this section: 1. The date(s) and time(s) investigator visited the site of the incident. 2. The person(s), (by name and title), the investigator spoke with at the site, e.g. reporter of the incident and site supervisors or management of the organization where the incident occurred, etc. Purpose of these discussions is to assess initial issues and needs of the investigation. B. Collecting Physical and Demonstrative Evidence The following information should be documented in this section: 1. Identify how the incident scene was secured, and if not, why not. 2. Identify and list physical evidence identified and logged. 3. Identify and list each piece of physical evidence collected. 4. Identify and chronologically list (by date, time, and name of person taking photo) any photographs or video taken. 5. Identify and list (by date and time) all other demonstrative evidence available to the investigation, e.g., diagrams, maps, floor plans, x-rays, etc. PA ODP CIPR Manual V1.0 3/1/12 Page 41

44 Appendix II - Sample Certified Investigation Report Format 6. Identify how the physical and demonstrative evidence was preserved after collection in order to maintain the chain of custody. C. Collecting Testimonial Evidence The following information should be documented in this section: 1. Briefly describe how potential witnesses were identified for interviewing. 2. Chronologically list all individuals interviewed. Include title, date, and time of each interview. 3. Identify the person(s), if any, as the alleged target(s) of the investigation. 4. Note the date and time alleged target(s) was removed from contact with individuals and placed on administrative leave or reassignment to other duties. If administrative leave or reassignment did not occur, note why. 5. If the right to representation exists, describe how the alleged target(s) or other witnesses were afforded this right. D. Collecting Documentary Evidence The following information should be documented in this section: 1. List written statements taken from individuals interviewed during the investigation. If identical to II.C.2. above, simply reference here; if not, create a chronological list of noting name, date, and time statement was prepared of all documents considered witness statements. 2. Identify and list all other documents collected in the case (business records of the organization, etc.). 3. Identify how business records collected as evidence were secured prior to, and after, collection. III. EVIDENCE SUMMARY (Note: this section is used to document the primary question[s] needing to be answered as a result of the investigation and to classify the direct and circumstantial evidence available to answer that question[s]). The following information should be documented in this section: 1. Identify and list the primary question(s) needing to be answered by the investigation (if multiple questions must be answered, list each one separately). 2. Classify and list all direct evidence available to answer each question. 3. Classify and list all circumstantial evidence available to answer each question. PA ODP CIPR Manual V1.0 3/1/12 Page 42

45 Appendix II - Sample Certified Investigation Report Format IV. INVESTIGATOR S ANALYSIS OF EVIDENCE PRESENTED IN SECTION III (Note: this section is used to document the analysis of evidence presented in the Section III: Evidence Summary above.) 1. For each question identified in Evidence Summary above, prepare a narrative analysis of the initial reconciliation of evidence and the reasons for the conclusions being drawn. Analysis of the evidence: Reasons for conclusions of evidence being presented: Certified Investigator Date PA ODP CIPR Manual V1.0 3/1/12 Page 43

46 Appendix II - Sample Certified Investigation Report Format V. ADMINISTRATIVE REVIEW, FINDINGS, RECOMMENDATIONS, AND IMPLEMENTATION (Note: Section I-IV of the report would be prepared by the Certified Investigator. Section V, the Administrative Review, is an important piece of the investigative process that should be completed by executive staff (or designee) of an organization. Executive staff should review all investigations completed in the organization prior to determining final conclusions and outcomes. This is done to ensure that key elements of a competently conducted investigation are in place, and that a well written Certified Investigation Report is prepared. Once those requirements are satisfied, Executive Staff should use the evidence presented to ensure all issues involving the individual s health and safety, as well as personnel and other systemic issues, are reviewed, prioritized, and appropriate actions are implemented.) Date Report Received: HCSIS Incident # 1. Was the incident reported in a timely manner? Yes No 1a. If not, please explain: (If you answer no please enter your corrective action plan in Section VI: Implementation) 2. Were protections provided to the individual? Yes No 2a. When appropriate, was the victim offered some type of assistance? Yes No 2b. List the type of assistance offered below? (e.g. counseling, opportunities to talk to staff, etc.): 3. If the incident involved a target, was the alleged target (s) reassigned or placed on leave? Yes No 3a. Date and time personnel actions occurred: 4. Were there injuries to the individual? Yes No 4a. If yes, was prompt medical treatment provided? Yes No 4b. Date and time injury discovered: 4c. Date and time medical treatment provided: 4d. Did the injuries result in hospitalization? Yes No 5. Did the investigation begin in a timely manner? Yes No 5a. If not, please explain: 6. Was the investigatory question(s) properly identified? Yes No 6a. If not, please explain: 7. Did the evidence collected and presented in the report by the investigator support their findings? Yes No PA ODP CIPR Manual V1.0 3/1/12 Page 44

47 Appendix II - Sample Certified Investigation Report Format 8. Did the evidence support a determination that abuse or neglect occurred? Yes No 8a. Do the administrative findings match the conclusion drawn by the Certified Investigator? (Please enter this information in HCSIS) Yes No 9. Were there violations of agency or facility policy involved in this incident? Yes No 9a. If yes, please explain: 10. Were notifications made in the appropriate timeframes? Yes No 10a. Was the family notified of the incident within 24 hours? Yes No 10b. If not please explain? 10c. When appropriate were notification requirements relating to The Older Adults Protective Services Act and Child Protective Services Law met? Yes No RECOMMENDATIONS AND IMPLEMENTATION OF CORRECTIVE ACTIONS BASED ON FINDINGS: 11. Were there any issues and, or concerns identified in the investigation that would lead to changes in individual(s) care, personnel, or other administrative and systemic practices? Yes No 11a. If yes, use the template below to create an action plan. Include information on what activities are to be completed, who is responsible for completing them, a target date for completion, and the date the action is completed Action Functional Area (e.g. Fiscal, Program Services, Personnel, etc.) Person(s)and Position(s) Responsible Target Date Status Date of Completion Review Status: To be continued (Due Date: ) Closed Administrative Findings: Confirmed Not Confirmed Inconclusive PA ODP CIPR Manual V1.0 3/1/12 Page 45

48 Appendix II - Sample Certified Investigation Report Format Reviewer(s) Name: Signature: PA ODP CIPR Manual V1.0 3/1/12 Page 46

49 Appendix III Evidentiary Rules Used to Reconcile or Weigh Evidence Physical evidence consistent with testimony Objectivity (relationships, motives) Independent corroboration of Principle's version of event Witness Testimony Capacity to see and hear Consistency of story over time Physical proximity and environmental factors affecting ability to see/hear PA ODP CIPR Manual V1.0 3/1/12 Page 47