There is always concern among both family members and providers that abuse and neglect of vulnerable populations can occur. Horror stories of such treatment have been chronicled in history, and there are still current reports of such atrocities (e.g., Bailey & Burch, 2016). As an organization, attention must be given to cultural and systems factors that can prevent such abuse and neglect. Additionally, a framework for response to identified abuse and neglect must be ready.
While the organizational and systemic strategies that can be used are not specific to any one organization, we have chosen to write this article from the perspective of Melmark, because the strategies used to prevent and respond to neglect and abuse are so linked to the organizational mission, core commitments, training, and systems.
Factors of abuse and neglect are multi-faceted and require a multi-tiered approach starting with organizational level processes all the way through individual employee actions. The Melmark mission, “Mission first, every individual, every day” and core commitments form the foundation of the culture.
The mission and core commitments are present through all levels of organizational practices. Each of the core commitments is related to the prevention of abuse and neglect. Below are descriptions of systems and processes influenced by the mission and core commitments that are relevant to this goal.
Strategic plan – The Melmark leadership demonstrates a commitment to building a culture emphasizing protection of individual rights by developing and implementing a strategic plan. A strategic plan details the organizational mission and values that guide organizational practices supportive of the desired culture. It also creates a roadmap of actionable steps to realize the mission and values.
Wage initiatives – The Melmark leadership team continuously advocates for living wages for employees. Not only do increased wages create a better personal life for employees, it is a commitment that helps establish a context of higher employee expectations, including protection of human rights. Melmark continues to develop and analyze strategies to ensure continued competitive wages, despite long-term funding shortfalls.
Hiring practices – Prevention of abuse and neglect of rights is more than background checks and clearances. Job applicants are explicitly asked about how their personal values and actions align with the Melmark mission and core commitments. Job candidates that cannot describe the importance of protecting human rights and the role of employees in that protection are considered a poor fit with Melmark’s mission and core commitments. A multi-step hiring process, involving multiple current employees, allows for multiple interactions and opportunities to assess fit with the expected culture.
Support departments – Melmark utilizes support departments such as Human Resources, Professional Development, Finance, Facilities, and Quality Assurance and Improvement to alleviate administrative burdens of direct service professionals. The reduction in administrative burden allows direct service professionals to have a singular focus on the care of individuals within their programs. Furthermore, desk activities (e.g., report writing) are reduced for program supervisors, increasing active presence in program areas supporting individual and employee needs.
Training – Melmark invests many resources training employees to high standards of care with the view that a better-trained employee is less likely to rely upon default practices that may lead to abuse and neglect. Melmark utilizes performance-based instruction (Brethower & Smalley, 1998) to ensure employees demonstrate expected performance and have frequent performance evaluations (i.e., monthly) to maintain learned skills. This training occurs via an intensive two-week orientation, a 90-day on-the-job training process, and monthly observations. The culture is one of perennial training, where all staff are continually evaluated, coached, and given feedback to ensure consistent excellent and humane care.
Supervisor presence – Melmark commits additional resources to increase supervisor presence in program service areas. Supervisor presence supports intensive training, monitoring of systems, safety checks, and another set of eyes for misconduct. In addition to informal supervision, supervisors provide formal supervision on a monthly basis (i.e., 1-1 meeting with employee to discuss performance, professional goals, solicit program feedback). Supervisors complete a yearlong training learning about evidence-based supervision methods utilized during informal and formal supervision practices. Supervisors are expected to be embedded into clinical settings, and to be continually evaluating the quality of interventions and interactions.
Evidence-based practices – Melmark uses scientific evidence and performance data to inform all decision-making including the creation and implementation of behavior support plans for individuals with maladaptive behaviors. Our clinicians maintain an active presence in the programs, provide hands-on training for staff, and conduct on-going fidelity checks on the implementation of the treatment plans. This serves to prevent staff from drifting from prescribed treatment plans and enables supervisors to detect changes in the fidelity of plan implementation early in the process.
High maintenance standards – In addition to creating a homelike environment, Melmark’s high standards for care of the homes ensures we can maintain a clean and safe environment. Our direct support staff are trained to report any and all issues they observe within the residences and program areas. The diverse skillset of our Facilities department allows us to quickly follow up on reports and fix issues in a timely manner.
Development of ethical decision-making skills – During monthly team meetings, employees discuss ethical scenarios, often publicly documented external cases of abuse, neglect, or fraud. The purpose is to reflect on ethical issues that arise in workplaces and compromise the care we provide to our individuals. Discussions are focused on identifying factors that led to the incident and ways in which Melmark can prevent such incidents from occurring. All staff are expected to process incidents and to learn from them; systems are put in place or altered to improve Melmark’s prevention of incidents.
Open communication – Families have the ability to report concerns to a supervisor at any time, day or night. Supervisors are trained to respond to reported concerns in a way that promotes the health and safety of the individual we serve. Additionally, Melmark actively reports incidents to funders and regulators, often requesting external review and support to ensure thorough and balanced investigations of reports.
Responding to Incidents
While these measures are in place to prevent incidents, incidents can still occur. As such, at Melmark, every employee is responsible for protecting and ensuring the safety and well-being of those we serve. In addition to preventative efforts noted above, Melmark maintains an incident management process, which incorporates procedures for reporting, investigating, and responding to all incidents with integrity and transparency. The chart below provides a life cycle of allegations requiring investigations.
Recognizing and Reporting Incidents
All Melmark employees are considered mandated reporters and as required by law, are trained to report all suspected cases of abuse and/or neglect not only internally but also, to protective services such as Adult Protective Services, Child Protective Services, and Older Adults Protective Services. Employees are fully informed upon hire and annually thereafter regarding mandatory abuse and neglect reporting laws and subsequent consequences of failing to follow the law, which may include criminal charges. Melmark employees are also knowledgeable on how to recognize signs of abuse and neglect as well as their responsibility to protect individuals from abuse and neglect.
Investigating and Responding to Incidents
Upon becoming aware of a reportable incident or an allegation of abuse and/or neglect of an individual, Melmark takes immediate action to ensure the health and safety of the individual involved. Any employee(s) accused of abuse, neglect or mistreatment of any kind is immediately placed on administrative leave until the investigation is concluded. Our Quality Improvement Department, comprised of state certified investigators, ensures that investigations are initiated immediately, are completed in a timely, objective, and thorough manner. The investigation process involves in-person interviews with all potential witnesses, review of documentation available for the investigation as well as consideration of all other forms of evidence, relevant to the investigation.
Upon conclusion of the investigation, the completed investigation report is reviewed by an administrative review committee which conducts a thorough review of the investigation report for quality, competency and determines the findings of the investigation. This team also determines recommendations and action plans that Melmark must implement to prevent such incidents from reoccurring.
Throughout the investigation process, Melmark ensures transparency and the involvement of oversight entities (e.g., Department of Health, Law Enforcement). Melmark communicates with families regarding allegations, the investigation process, and final determination.
Follow-Up and Trend Analysis
As an effort to respond to incidents at an organizational level, Melmark holds consistent monthly Health and Safety meetings with leadership teams to ensure continuous communication and dialogue regarding incidents, investigation outcomes and actions taken to protect the health and safety of those we serve. The health and safety meetings bring various leadership teams together to review data, identify trends of incidents and discuss how we can continue to use or improve our processes to prevent abuse and neglect.
Abuse and neglect may occur in human service organizations. However, organizational philosophy and practice should prioritize prevention via proactive strategies and minimization of impact to the individual via active response to allegations. At every layer of the organization, and in all aspects of the organizational structure, commitment to excellent care can be infused. Valuing employee contributions, and demonstrating that value through wage incentives, helps attract and retain excellent employees. Placing an emphasis on supervision and training is one of the most effective means of ensuring quality care. A commitment to evidence-based practice and to the development of ethical decision-making skills helps all employees to be continually analyzing their behavior in the treatment context. Emphasizing high standards in all aspects of care and requiring open communication at all levels of the organization help to make the organization nimble in meeting challenges, responsive to problems that arise, and committed to the implementation of successful resolutions. Transparency in the investigation process, and multiple layers of checks and balances regarding the outcome of such investigations, ensures that incidents are objectively assessed.
While all organizations are vulnerable to the occurrence of abuse and neglect, certain administrative actions can reduce their likelihood. Creating a culture of compassionate care starts with an articulated mission and vision with explicit core commitment values and is strengthened by strong training and supervision. The process is also assisted by a thorough evaluation of incidents, transparent communication, and a commitment to strengthening systems when incidents suggest the need to revamp procedures or retool staff skill sets. Ensuring humane care, and preventing abuse and neglect, is an organizational commitment; every individual, every day.
Shawn P. Quigley, PhD, BCBA-D, is Executive Director, PA Division, Jennifer Ruane, MS, BCBA, LPC, Director of Professional Development and Clinical Training, Mary Odira, MS, is Director of Quality Improvement, Mary Jane Weiss, PhD, BCBA-D, is Senior Director of Research, Rita M. Gardner, MPH, BCBA, LABA, is President and CEO, and Frank L. Bird, MEd, BCBA, LABA, is Vice President & Chief Clinical Officer at Melmark Inc. For more information, please visit www.melmark.org.
Bailey, J. S. & Burch, M. R. (2016). Ethics for behavior analysts (3rd Ed.) New York, NY: Routledge.
Brethower, D. & Smalley, K. (1998). Performance-based instruction: Linking training to business results. San Frncisco, CA: Jossey-Bass Pfeiffer.