Observations
Based on a review of administrative documentation the facility failed to follow their Facility PREA Response Plan Following Resident Report policy.
Per the Facility PREA Response Plan Following Resident Report policy, reporting duties include notifying the alleged victim's parents/legal guardians, unless the facility has official documentation that they should not be notified. The actions required after a report of sexual harassment include fully documenting the incident in an Abraxas Incident Report. Also, the alleged victim is to be referred to a Mental Health Practitioner for re-assessment to determine if any issues need to be addressed. This re-assessment is to be documented, and a copy placed in the investigation file.
The facility did not provide documentation of the notification of the parents/guardians, or lack of notification due to having official documentation not to contact the parents/guardians. Nor was documentation of an Abraxas Incident Report or a Mental Health Practitioner re-assessment provided.
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Plan of Correction
Following the receipt of the deficiency (exit date September 3, 2025), the facility's PREA Compliance Manager audited the documentation related to the PREA allegation in question. Per the facility's PREA Response Plan Following Resident Report Policy (PREA Response Plan), an incident report was completed, notification was made to the resident's parents, the alleged victim was referred to a mental health practitioner for reassessment, and a medical exam was completed. These services were completed within 24 hours of the PREA Compliance Manager receiving the allegation. Documentation of these services was completed in the client's electronic health record, was available at the time of the DDAP unusual incident investigation and would have been provided if requested.
To support ongoing compliance with the facility's PREA Response Plan, on October 24, 2025, the PREA Compliance Manager will provide a refresher training to the Abraxas I Leadership Team regarding the facility's procedures and responsibilities following the receipt of an allegation of sexual abuse or sexual harassment of a client. This training will be documented on a training roster and recorded in each employee's training file.
The facility's response, and the investigations of alleged of sexual abuse or sexual harassment occurring at the facility are monitored by the PREA Compliance Manager to verify compliance with policies and procedures as well as the PREA standards. If variation from policy occurs during any part of the facility's response or during the investigatory process, the Abraxas PREA Coordinator and Abraxas I Executive Director will be notified, and supervisory conferences will be completed with necessary employees to provide additional instruction and support. |