Investigations

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Training Programs

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Conducting Serious Incident Investigations

Students attending this 3 day course will learn fundamental principles of investigation, including:

  • The role of speed, thoroughness and objectivity in the conduct of a real investigation.
  • Fundamental definiton of the types and forms of evidence. 
  • Techniques for collecting detailed information from witnesses. 
  • Methodologies for preserving testimonial evidence and the collection of other documentary evidence.
  • Reconciling conflicting evidence.
Day 1

Introduction of Program and Participants

I.  Identification of Common Problems Associated with the Conduct of
Incident Investigations

  • small group discussion
  • class discussion

II.   The Investigative Process

  • lecture
  • class discussion

III.   Critical Concepts Associated with a REAL Investigation: Speed, Thoroughness, Objectivity

  • small group discussion
  • class discussion

IV.   Rules for Collecting Various Forms of Evidence when Conducting a REAL Investigation

  • small group discussion
  • class discussion
  • demonstrations
Day 2

V.   Understanding Evidence: Additional Information on Definitions Associated with Investigations, and Practice Using the Definitions

  • lecture
  • small group discussion
  • class discussion

VI.   Interviewing Cooperative Witnesses

  • lecture
  • small group discussion
  • role plays
  • class discussion

VII.   Inteviewing Cooperative Witnesses: How to Add Organization and Detail to an Interview

  • lecture
  • demonstration
  • small group discussion
  • role plays
  • class discussion

VIII.   Interviewing Consumers

  • small group discussion
  • class discussion

IX.   Organizing an Investigation

  • small group discussion
  • class discussion
Day 3

X.   Collecting Physical Evidence

  • small group discussion
  • demonstration (optional)
  • class discussion

XI.   Interviewing Uncooperative and Antagonistic Witnesses

  • small group discussion
  • role plays
  • class discussion

XII.   Taking Written Statements

  • lecture
  • demonstration
  • practice exercise
  • class discussion

XIII.   Reconciling Conflicting Evidence

  • practice exercise
  • lecture
  • class discussion

IV.   Summary and Evaluation

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Conducting State Survey Investigations: Techniques for Observation, Interviewing and Record Review

This course is designed for state survey agencies with the responsibility of investigating incident and complaints. It is a four day program based on the three primary methods used during the survey process to organize an investigation and promote a systematic collection of facts on which conclusions are based. It is designed to teach participants the fundamental
principles of investigation including:

  • Organizing an investigation and off-site preparation activities.
  • Principles of observation and the collection and preservation of physical evidence.
  • Interviewing techniques for collecting detailed information from witnesses and preserving testimonial evidence.
  • Collecting documentary evidence and issues related to record review including the analysis of incidents for trends and patterns.
  • Weighing evidence to reach supportable conclusions.
  • Specific investigative processes related to incidents of abuse, neglect and deaths.
Day 1

Introductory Issues

I.   Introduction of Program and Participants

II.   Difficult Problems

  • Small group discussion
  • Exercise: Difficult Problems
  • Class discussion

III.   Investigative Definitions and Concepts

  • Lecture (use PowerPoint)
  • Class discussion
  • Break (15 minutes)
  • Small group discussion
  • Exercise: Creating the Investigatory Questions
  • Class discussion

Observation

IV.   Values: Speed, Thoroughness and Objectivity

  • Small group discussion
  • Exercise: Investigation Questions
  • Class discussion
  • Observation

V.   Organizing an Investigation

  • Small group discussion
  • Exercise: Organizing an Investigation: The Offsite Survey Preparation Worksheet.
  • Class discussion

VI.  Counting Passes

  • Individual exercise
  • Class discussion

VII.   Observation: Some Questions

  • Small group discussion
  • Exercise: Observation: Some Questions
  • Class discussion

VIII.   Creating Demonstrative Evidence

  • Small group activity
  • Exercise: Case Study
  • Class discussion
Day 2

IX.  Review, Day 1 Content

  • Individual Exercise
  •      Review Quiz
  • Small group discussion
  • Class Discussion

Interviewing

X.   Conducting Interviews: Rules

  • Short lecture (Types of Interviews)
  • Small group discussion
  • Exercise: Incident Interview Rules
  • Class discussion

XI.   Incident Interview: Role Play 

  • Short lecture (Communications Model)
  • Small group discussion
  • Exercise: Role Play #1
  • Class Discussion

XII.   Incident Interview: Thoroughness and Objectivity

  • Short lecture
  • Class discussion
  • Demonstration

XIII.   Incident Interview: Role Play

  • Small group discussion
  • Exercise: Role Play #2
  • Role plays
  • Class discussion

XIV.   Exploratory Interviews

  • Short lecture
  • Small group discussion
  • Exercise: An Injury of Unknown Origin
  • Class discussion

XV.   Interviewing Individuals with Mental or Intellectual Disabilities

  • Small group discussion
  • Exercise: Interviewing Individuals with Mental or Intellectual Disabilities
  • Class discussion

Homework: Read Chapters 4-5, 7

Day 3

XVI.   Interviewing Uncooperative Witnesses

  • Small group discussion
  • Exercise: Uncooperative Witnesses
  • Role plays
  • Class discussion

XVII.   Characteristics of Testimonial Evidence

  • Short lecture
  • Small group discussion
  • Exercise: Understanding Evidence
  • Class discussion

XVIII.   Preserving Testimonial Evidence

  • Small group discussion
  • Exercise: When to Take a Written Statement
  • Class Discussion

XIX.   Taking Written Statements

  • Short lecture
  • Demonstration
  • Role plays
  • Exercise: Case Study
  • Class discussion
  • Record Review

XX.   Introduction

  • Short lecture
  • Small group discussion
  • Exercise: Some Questions Related to Record Review
  • Class discussion

XXI.   Practice Exam

  • Individual activity
  • Exercise: Practice Exam
  • Class discussion

XXII.   Case Study – Record Review

  • Small group discussion
  • Exercise: Case Study: Record Review
  • Class discussion

Homework: Read Chapters 7-8 and study for exam

Day 4

XXIII.   Trends and Patterns

  • Short lecture
  • Small group discussion
  • Exercise: Trends and Patterns: Incident Data
  • Class discussion

XXIV.   Weighing Evidence and Drawing Conclusions

  • Short lecture
  • Small group discussion
  • Exercise: Weighing Evidence and Drawing Conclusions
  • Class discussion

XXV.   Resolving Conflicting Eyewitness Testimony

  • Small group discussion
  • Role plays
  • Class discussion
  • Short lecture

Exam

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Mortality Review and Death Investigations

Introduction of Program and Participants

  • Provide students with an overview of the content of the training program.
  • Provide students with an understanding of the teaching methods that will be used in delivering the content.
  • Create an environment that allows students to be comfortable talking to the instructor and their fellow participants.
Day 1

I.   The Significance of Death

The objective of this module is to identify whatever unique issues are raised by addressing death as an "incident," including understanding the relationship of death incidents to concepts.

II.   Classifying Deaths

The objectives of this module are to:

  • Create a typology of all deaths, including definitions for the following variations: expected, unexpected, accidental, medical, suicide, mistreatment (abuse and neglect), homicide, and suspicious death.
  • Understand the relationship of this typology to the proper classification of deaths in the incident management and mortality review processes.
  • Practice applying this typology to a set of facts in order to properly classify deaths.

III.   Mortality Review and the Incident Management Process

The objective of this module is to familiarize the participants with the various elements of the mortality review process and their relationship to the incident management process.

IV.   Death Investigations: An Introduction

The objectives of this module are to:

  • Practice applying elements of the mortality review process to the facts of a case when seeking to triage responses to deaths.
  • Review the concept of the investigatory question.
  • Practice developing investigatory questions for various types of deaths.

V: Explanation: Proximate, Antecedent and Root Cause

The objectives of this module are to:

  • Identify and distinguish among proximate, antecedent and root causes of an incident (particularly those involving death). Practice applying the definitions associated with each to a set of facts.

VI.   Special Problems When Conducting Death Investigations

The objectives of this module are to:

  • Discuss the difficulty in acquiring certain evidence (e.g., autopsy reports) in a timely and thorough manner in cases of an individual's death.
  • Identify background interviews that are likely to be important in a death investigation.
  • Determine the role of an autopsy report in a death investigation.

VII.   Conducting Interviews During Death Investigations

The objectives of this module are to:

  • Explore the interaction between the emotional circumstances of a death, particularly an unexpected death, and the need to interview friends and family in a timely manner.
  • Introduce the need for an interview to family, particularly in light of the possibility of legal liability associated with any particular death. 
  • Identify the best manner to preserve testimony of family members when they do not constitute incident witnesses in an investigation.

VIII: Day #1 Review

Day 2

The objectives of this module are to:

  • Review the content of the first day of the training program.
  • Allow students to identify those elements that have been most helpful in understanding the mortality review process.

IX.   Medical Review: The Form

The objectives of this module are to:

  • Familiarize students with the medical review format which will be used for all deaths.
  • Allow students to assess potential difficulties in using the medical review form.

X.   Using the Medical Review Results

The objectives of this module are to:

  • Allow students to practice using medical review results to better understand the relationship between the medical review process and other elements of the larger mortality review process.

XI.   Root Cause Analysis: Introductory Questions

The objectives of this module are to:

  • Identify the role of the root cause analysis in the context of mortality review.
  • Identify problems that members of a root cause analysis committee are likely to encounter when participating in that process.

XII.  Root Cause Analysis: Asking Why?

The objectives of this module are to:

  • Explore the central role of the question "why" in conducting a root cause analysis.
  • Identify the relationship between proximate cause, antecedent cause and root cause on the matrix used to display the root cause process
  • Provide an opportunity to understand the use of research methodologies in answering the question "why".

XIII.   Mortality Review: General Questions

The objective of this module is to review the relationship between the overall mortality review process in the context of the medical review, death investigation and root cause analysis processes.

XIV.   Mortality Review: Considering Data I

The objectives of this module are to:

  • Practice analyzing incident data in the context of a particular death.
  • Identify the types of data that will help a mortality review committee understand how to best avoid unexpected deaths.

XV.   Mortality Review: Considering Data II

The objective of this module is to practice developing recommendations to prevent unexpected deaths based on the incident data considered in module XIV.

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Facilitating Root Cause Analysis Process

This course provides participants with the skills to use this powerful interdisciplinary tool to help organizations identify underlying causes of serious incidents that can have an impact on those we serve. The technique includes not just the identification of root causes, but the requirement that organizations identify and implement potential solutions. The principles taught are consistent with The Joint Commission definitions of root cause analysis and use with sentinel events.

  1. Introduction of Program and Participants
  2. Root Cause Analysis: A Review
    1. Diagram Process
    2. Describe Final Report Format
    3. Identify Tools
      • Facilitating a meeting
      • Review of other tools described in section III
  3. Facilitation
    1. Facilitation: What is it?
      • Definition
      • Role of the facilitator
    2. Facilitation in Practice
      1. Operationalizing the problem
        • small group discussion
        • fish bone diagram
        • research (not an Investigation)
      2. Identifying Causes
        • Proximate, antecedent, "root"
        • Using a "why" matrix
      3. Identifying Solutions
        1. Brainstorming
        2. Affinity process and relationship to fishbone diagram
        3. Voting tool
        4. Assessment of ideas
          • Legality?
          • Consistent with mission?
          • Cost/benefit analysis
          • Advantage/Disadvantage analysis
        5. Consensus
  4. Summary and Evaluation
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Introduction to Investigations

This is a one-day overview of the investigations function as well as the relationship between the investigator's work and the responsibilities of unit and program supervisors.

Introduction of Program and Participants

  1. Identification of Common Problems Associated with Investigations
    • small group discussion
    • class discussion
  2. Important Definitions: Types and Forms of Evidence 
    • lecture
    • class discussion
  3. Values of a REAL Investigation: Speed, Thoroughness, Objectivity
    • small group discussion
    • class discussion
  4. Rules for Collecting Evidence
    • small group discussion
    • class discussion
    • demonstrations
  5. Organization of an Investigation
    • lecture
    • class discussion
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Advanced Course in Investigations

This course is limited in registration to those who have already attended the course, Conducting Serious Incident Investigations. Class size is limited to 15 persons. Participants will practice various tasks learned in the three-day program and will be required to perform competency-based exercises about which they will receive written feedback from the instructor. The class will also spend considerable time learning to write final reports. Also, each participant will receive handout materials which will help in developing self-assessment capabilities.

Day 1

I.   Introduction of Program and Participants

II.  Review of the Types and Forms of Evidence

  • class discussion
  • individual exercise
  • small group discussion
  • class discussion

III.   Review of Investigative Procedures and the Collection of Evidence

  • small group discussion
  • class discussion

IV.   Conducting an Incident Interview

  • class discussion
  • demonstration

V.   Slicing the Bologna

  • role play (video taped)
  • demonstration

VI.  Review of Statement Taking Procedures

  • class discussion
  • demonstration

VII.  Written Statements

  • small group discussion
  • class discussion

VIII.   Evaluating Written Statements

  • small group discussion
  • class discussion

IX.   Tape Recording Statements

  • class discussion

X.   Final Investigative Report

  • class discussion
  • small group discussion
  • class discussion
Day 2

XI. Conducting Exploratory Interviews

  • class discussion
  • small group discussion
  • class discussion

XII. Conducting Follow-up Interviews

  • class discussion
  • small group discussion
  • class discussion
  • role play
  • class discussion

XIII. Writing a Final Report

  • small group discussion
  • class discussion
  • small group discussion
  • class discussion

XIV. Individual Role Plays and Statement Taking

During the balance of day #2, participants will complete individual assignments which the instructor will evaluate. Each participant will be asked to take a written statement and turn it in to the instructor. The instructor will send via mail a written evaluation of the effort. Also, each person will conduct an interview on video tape with just the instructor present, after
which the instructor will review and provide feedback to the participant.

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Weighing Evidence

This course is limited in registration to those who have already attended the course, Conducting Serious Incident Investigations. The course provides information regarding how to perform one of the most difficult aspects of conducting an investigation: analyzing the evidence and reaching a conclusion. This program addresses the following issues related to determine what "really" happened in an analytical manner:

  • What does the phrase, "burden of proof," mean? What are the appropriate standards in cases involving civil investigations of  abuse and neglect?
  • How does the quality of the investigative process affect the ability of an agency to reach appropriate conclusions?
  • What factors assist an agency in reconciling differences among competing possibilities about what occurred and why it occurred in the context of a serious incident investigation?
  • What internal administrative processes will help organizations routinely arrive at valid investigatory conclusions.

 I.   Introduction of Program and Participants

 II.   Investigatory Questions

  • short lecture
  • small group discussion
  • class discussion

 III.   Investigatory Errors

  • small group discussion
  • class discussion

IV.   Dealing with Circumstantial Evidence Cases: Exclusive Opportunity

  • small group discussion
  • class discussion

V.   Standards of Proof

  • small group discussion
  • class discussion
  • small group discussion
  • class discussionandards of Proof

VI.   Drawing Conclusions

  • small group discussion
  • class discussion
  • small group discussion
  • class discussion

VII.   Summary and Evaluation

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Writing Final Reports

This course is limited in registration to those who have already attended the course, Conducting Serious Incident Investigations.  This is a one-day program designed to help investigators write final investigations reports that clearly and concisely communicate to those with a need to know what evidence was collected and how it was collected.

I.   Introduction of Program and Participants

II.   The Investigative Report: Its Form and Function

  • small group discussion
  • class discussion

III.   Recording Investigative Activities

  • Part 1: Introduction
    • Individual Activity
    • class discussion
  • Part 2, A&B: Physical and Demonstrative Evidence
    • Individual Activity
    • class discussion
  • Part 2, C: Testimonial Evidence
    • Individual Activity
    • class discussion
  • Part 2, D: Documentary Evidence
    • Individual Activity
    • class discussion

IV.   Summarizing Evidence

  • small group discussion
  • class discussion

V.   Findings and Analysis

  • individual activity
  • class discussion

VI.   Summary and Evaluation

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Understanding Serious Incident Investigations

This one-day program provides information to direct care employees about the conduct of serious incident investigations

  1. Introduction of Program and Participants
  2. Why Conduct an Investigation?
    • small group discussion
    • class discussion
  3. What is a REAL Investigation?
    • short lecture
  4. Rules Governing a REAL Investigation
    • small group discussion
    • class discussion
  5. Role of Direct Care Staff
    • small group discussion
    • class discussion
  6. Summary and Evaluation
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Conducting Investigations: Refresher Course

Students who have attended LRA's three-day course, Conducting Serious Incident Investigations, are eligible to register for this one-day offering. The course will review the content of the three-day course, providing new and challenging exercises which allow students to reinforce their understanding of the investigatory process.

Students are encouraged to bring their Investigations Manual to the class.

  1. An Incident Report: What to Do?
    • small group discussion
    • class discussion
  2. Clarifying the Report
    • small group discussion
    • class discussion
  3. Beginning the Systematic Collection of Facts
    • small group discussion
    • class discussion
  4. Collecting Physical and Demonstrative Evidence
    • small group discussion
    • class discussion
  5. Identifying Incident Witnesses
    • small group discussion
    • class discussion
  6. Conducting an Incident Interview
    • small group discussion
    • class discussion
  7. Preserving Testimonial Evidence
    • small group discussion
    • class discussion
  8. Documentary Evidence, Background and Follow-up Interviews
    • small group discussion
    • class discussion
  9. Resolving Discrepancies in Evidence
    • small group discussion
    • class discussion
  10. Summary and Evaluation
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Interviewing Persons with Disabilities

This half-day program provides investigators with specific interviewing techniques that will enhance their ability to obtain and document information from this group of witnesses and to do so in a manner which is supportive and respectful.

  1. Introduction of Program and Participants
  2. Communication Model
    • lecture
    • class discussion
  3. Communication Barriers
    • small group discussion
    • class discussion
  4. Preparing for the Interview
    • small group discussion
    • class discussion
  5. Conducting the Interview
    • small group discussion
    • class discussion
  6. Special Problems
    • small group discussion
    • class discussion
  7. Additional Advice
    • small group discussion
    • class discussion
  8. Evaluation
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