Contents of Reports of Suspected Cases

All reports of suspected patient or resident abuse, neglect, mistreatment or misappropriation of patient or resident property made pursuant to 105 CMR 155.004 shall contain the following information, where applicable: (A) The name and gender of the patient or resident who the reporter suspects has been abused, neglected or mistreated or had property misappropriated; (B) The age of the patient or resident, if known to the reporter; (C) The home address of the patient; (D) The name and address of the facility in which the resident resides; (E) The name, address, and telephone number of the home health agency, homemaker agency, or hospice program involved; (F) The name, address and telephone number of the reporter and where such reporter may be contacted; (G) If known to the reporter, the name and position of the accused, and also, if known, any other documented allegations of patient or resident abuse, neglect or mistreatment or misappropriation of patient or resident property by the accused; (H) Any information relative to the nature and extent of the alleged abuse, neglect, mistreatment or misappropriation of the patient’s or resident’s property; (I) If known to the reporter, any documented information relative to prior abuse, neglect, or mistreatment of such patient or resident or misappropriation of such patient or resident’s property; (J) The circumstances under which the reporter became aware of the alleged abuse, neglect, mistreatment or misappropriation of property; (K) If known to the reporter, whatever action, if any, was taken to treat or otherwise assist the patient or resident; (L) Any other information which the reporter believes might be helpful in establishing the cause of the alleged abuse, neglect, mistreatment or misappropriation of property and the person or persons responsible therefor; and (M) Such other information as may be required by the Department.