See below message from Pam Clayton, GHCA VP Quality Advancement & Regulatory Affairs:

The Healthcare Facility Regulation Division (HFRD) recently conducted a comprehensive review of guidelines for reportable incidents and allegations and has provided guidance. Click here to view.

The guidance includes what should be reported; what should be included in a comprehensive investigation of a reportable incident; and, the revised form that should be used to file the initial report to HFRD, effective immediately. Reportable incidents include the following:

  • Verbal abuse
  • Sexual abuse
  • Physical abuse
  • Mental abuse
  • Neglect
  • Exploitation / Misappropriation of resident property
  • Mistreatment
  • Injuries of unknown source

Regulations do not provide for defining or reporting an elopement. The determination of an elopement must be evaluated on an individual basis consistent with the resident’s comprehensive assessment and plan of care. Elopements must be reported consistent with a center’s disaster plan.  Please carefully review your disaster plan to ensure staff members understand guidance relative to a response to an elopement. Also, please review the updated reporting guidelines and investigative tool in detail with your staff.

I am pleased to share that HFRD is now conducting desk reviews of select plans of correction (POCs). The practice of remote review is positive for providers and will allow the agency to more appropriately deploy resources and should positively impact timelines. Criteria for selection includes no harm or jeopardy citations; no complaints since conclusion of standard survey; and, no history of yo-yo compliance (or “poor” reputation). Please respond in a timely manner if you are notified of the intent to conduct a remote review. HFRD reports a delayed response to request for information and documentation in some instances.

The organizational (regional) structure for the agency and updated contact information for key HFRD staff was included in Friday’s Newsfront. Please distribute this information to your leadership staff to ensure they are reaching out to the appropriate staff at HFRD when necessary. We will post the contact information along with the updated reporting guidelines and form to the GHCA Quality website. Additionally, the information presented by Chief Simon at the mid-year convention, which highlights best practices related to high risk areas of compliance, will be posted to the site.

For questions, please feel free to contact me at or (678)-902-9224.

Cc:  Melanie Simon, Chief- HFRD
Norma Jean Morgan, Deputy Chief- HFRD
Andrea Miranda, Long Term Care Director
Tony Marshall, GHCA President & CEO