PROTECTING PEOPLE FROM HARM: EVALUATING THE QUALITY …€¦ · 2. CIPR Form 2: Witness Testimony and Written Statements 3. CIPR Form 3: Other Documentary Evidence In the context

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.

2012

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

ODP - Evaluating the Quality of Certified Investigations

CIPR Manual

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 ............................................................................... 10

Part III: The CIPR Tool and Related Forms ............................................................................. 11

Part IV: CIPR Users Guide ....................................................................................................... 12

General Guidelines .................................................................................................................. 12

CIPR Tool Section I: Initial Response to the Incident Report ................................................... 13

CIPR Tool Section II: Identification and Collection of Evidence ................................................ 15

CIPR Tool Section III: Certified Investigation Report (CIR) ..................................................... 24

Appendix I: CIPR Tool and Supplemental Forms ................................................................... 30

Appendix II: Sample Certified Investigation Report (CIR)...................................................... 41

Appendix III: Evidentiary Rules to Reconcile or “Weigh” Evidence ..................................... 46

Appendix IV: Stages of the Investigation Process ................................................................. 47


PA ODP CIPR Manual V1.0 3/1/12 Page 1

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 # 6000-04-01

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 2001. 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.



ODP also issued the Certified Investigations Bulletin #00-04-11 (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.



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.



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:



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.



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 Providers1:

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.



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.



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.



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.



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.



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.



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.



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 (1st

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.



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.



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.



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



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.



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.



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.



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 1.

8. 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



(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.



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.



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.



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.



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 4.

5. 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



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.



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.



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.



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.



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.

State of Pennsylvania/Office of Developmental Programs (ODP) Certified Investigation Peer Review (CIPR) Tool

HCSIS Incident #/Organization: _______________________________________ Date of Evaluation: __________ ____________

Certified Investigator: _________________________________ 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 (1st

witness statement taken within 24 hrs of assignment)?

Date/time of 1st 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: ___________________________






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?






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)?






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?






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: ______________________

CIPR FORM #1: PHYSICAL AND DEMONSTRATIVE EVIDENCE

HCSIS Case #: _____________________ Date of Review: ___________________________ CI Name: __________________________ 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

CIPR FORM #1: PHYSICAL AND DEMONSTRATIVE EVIDENCE



Table 3: Demonstrative Evidence - Other

List Relevant Demonstrative

Evidence

Identified?

(Y/N/NA)

Collected?

(Y/N/NA) NOTES

CIPR FORM #2: WITNESS TESTIMONY AND WRITTEN STATEMENTS



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

CIPR FORM #2: WITNESS TESTIMONY AND WRITTEN STATEMENTS



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)?

CIPR FORM #3: OTHER DOCUMENTARY EVIDENCE



TABLE 1: OTHER DOCUMENTARY EVIDENCE

List Relevant Documentary

Evidence

Collected?

(Y/N)

Date

Collected Notes

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.



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.



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



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



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

1.

2.

3.

4.

5.

6.

Review Status: To be continued (Due Date: ) Closed

Administrative Findings: Confirmed Not Confirmed Inconclusive



Reviewer(s) Name: _________________________ Signature: ______________________________

Appendix III – Evidentiary Rules Used to Reconcile or “Weigh” Evidence


Witness Testimony

Physical evidence

consistent with testimony

Independent corroboration of

Principle's version of event

Consistency of story over time

Physical proximity and environmental

factors affecting ability to see/hear

Capacity to see and hear

Objectivity (relationships,

motives)

Appendix IV – Stages of the Investigation Process


STAGE OF INVESTIGATION RESPONSIBILITY KEY TASKS AND ACTIVITIES

Stage 1 INTAKE

PRESERVE EVIDENCE (Incident Identified)

Agency Point Person Site Supervisors

Agency Management

1. Provide medical treatment as necessary. 2. Secure the scene. 3. Identify, keep, separate witnesses. 4. Remove alleged target(s) from contact

with individuals receiving services 5. Secure documentary evidence. 6. Assign the CI.

Stage 2 IDENTIFY COLLECT

(Arrive at scene)

Certified Investigator 1. Review activities of intake and preservation with management.

2. Review incident with Reporter. 3. Identify and collect physical and

demonstrative evidence. 4. Sort, classify, and interview witnesses, 5. Obtain written statements. 6. Identify & collect other documentary

evidence.

Stage 3 ANALYSIS

PRESENTATION (Review and Reconcile)

Certified Investigator 1. Review and assess evidence collected. 2. Conduct background interviews. 3. Conduct follow-up interviews. 4. Conduct final reconciliation of evidence. 5. Prepare Certified Investigation Report,

Sections I-IV.

Stage 4 QUALITY REVIEW

(Final decision-making and closing the investigation)

1. Agency Management 2. Incident and, or Risk

Management Committee

3. Human Rights Committee

4. Agency Board of Directors

1. Review competency and quality of investigation.

2. Determine final conclusions: confirmed, unconfirmed, or inconclusive.

3. Determine recommendations and action plans.

4. Implement recommendations and action plans.

Documents

PROTECTING PEOPLE FROM HARM: EVALUATING THE QUALITY …€¦ · 2. CIPR Form 2: Witness Testimony and Written Statements 3. CIPR Form 3: Other Documentary Evidence In the context