Pennsylvania Physician Ebook Continuing Education

This interactive Pennsylvania Physician Ebook contains 21 hours of continuing education. To complete click the Complete Your CE button at the top right of the screen.

Pennsylvania Continuing Medical Education

PENNSYLVANIA MEDICAL LICENSURE PROGRAM

MANDATORY CME REQUIREMENTS FOR PENNSYLVANIA LICENSE RENEWAL ENCLOSED PROGRAM INCLUDES: • 3 CREDIT HOURS Child Abuse (Mandatory) • 5 CREDIT HOURS Opioid Education (Mandatory) • 13 CREDIT HOURS Patient Safety (Mandatory)

YOUR ALL-IN-ONE MANDATORY CME PROGRAM

In support of improving patient care, NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

CME FOR:

AMA PRA CATEGORY 1 CREDITS ™ MOC STATE LICENSURE

AVAILABLE ONLINE AT: PA.CME.EDU

CME DEADLINE: DO : 10/31/2026 • MD : 12/31/2026

PENNSYLVANIA PHYSICIAN

Dear Colleagues,

As a condition of biennial license renewal, all mandated reporters must complete at least two (2) credit hours of board- approved education in child abuse recognition and reporting. Pennsylvania physicians (MD/DO) with a DEA registration must additionally complete at least two (2) credit hours of opioid education, unless exempt. Lastly, all physicians must complete at least twelve (12) credit hours in the area of patient safety/risk management, unless exempt. The InforMed Pennsylvania Medical Licensure Program is designed to fulfill these mandatory CME requirements of the Pennsylvania State Boards of Medicine and Osteopathic Medicine, as well as earning points for MOC and MIPS. Completion of the program satisfies three (3) credit hours of child abuse recognition and reporting, five credit (5) hours of opioid education, and twelve (12) credit hours on patient safety.

Thank you for choosing lnforMed as your CME provider. We strive to create a high-quality, streamlined program for our colleagues. Please contact us with any questions, concerns, or suggestions.

Best Regards,

The lnforMed CME Team

We are a nationally accredited CME provider. For all board-related inquiries please contact:

State Board of Medicine | 2525 N 7th Street Harrisburg, PA 17110 | (717) 783 -1400

BOOK.CME.EDU

BOOK CODE: MDPA2126

1-800-237-6999

What’s Inside

CHILD ABUSE IDENTIFICATION AND REPORTING: THE PENNSYLVANIA REQUIREMENT COURSE ONE | 3 CREDIT HOURS SATISFIES THE CHILD ABUSE REQUIREMENT In 2020, there were 4,593 substantiated reports to child abuse in Pennsylvania. Healthcare professionals, regardless of their discipline or field, are in a unique position to assist in the identification, education, and prevention of child abuse and neglect. This course describes how victims of abuse can be accurately identified and provides the community resources available in the state of Pennsylvania for child abuse victims. Mandated reporter laws will also be outlined.

OPIOID SAFETY: BALANCING BENEFITS AND RISKS COURSE TWO | 5 CREDIT HOURS SATISFIES THE OPIOID EDUCATION /PRESCRIBING OPIOIDS REQUIREMENT

Opioid analgesics are approved by the FDA for the treatment of moderate or severe pain. However, individual patients differ greatly in clinical response to different opioid analgesics, and patient populations show widely variable response to the same opioid and dose. These response variations make opioid prescribing challenging. Further, the important role of opioid analgesics is broadly accepted in acute pain, cancer pain, and palliative and end-of-life care, but it is controversial for the management of chronic noncancer pain. Previous opioid prescribing guidelines have been critiqued for lacking a patient-centered approach and failing to emphasize individualization of therapy. This prompted the 2022 revision of the CDC’s opioid prescribing guidelines, the draft of which is outlined in this course. Opioids are not a panacea for pain, nor are they safe and effective for every patient. However, they can be a useful tool, and knowledge of medical advances can give clinicians greater confidence to safely and effectively prescribe these drugs.

BURNOUT IN PHYSICIANS COURSE THREE | 5 CREDIT HOURS SATISFIES FIVE (5) CREDIT HOURS FOR THE PATIENT SAFETY REQUIREMENT

Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment. Levels of burnout are high among physicians, with even higher rates among physicians in training. High degrees of job dissatisfaction and stress precede burnout, making it incumbent on physicians to recognize stress early to help prevent burnout before it occurs. Preventing burnout is vital not only for the well-being and professional preservation of physicians but also for ensuring optimal patient outcomes. Several personal and professional lifestyle strategies can help physicians cope with stress, achieve better work-life balance, and become more engaged in their work.

FALLS AND FALL PREVENTION COURSE FOUR | 3 CREDIT HOURS SATISFIES THREE (3) CREDIT HOURS FOR THE PATIENT SAFETY REQUIREMENT

Injuries sustained by falling, especially falls among the elderly, can lead to immediate and long-term sequelae, including death. Health professionals responsible for hospital and long-term facility care have increasingly worked to develop programs that reduce fall risk among inpatients. Given the growing expansion of the aging population, it is equally important that primary care providers pay close attention to risk assessment and fall prevention among community-dwelling older adults. This course will review the epidemiology and scope of falls and fall-related injuries, available clinical guidance for screening and fall risk assessment, and management strategies for fall prevention in community and healthcare settings, emphasizing the fall burden associated with aging.

82 RISK MANAGEMENT

COURSE FIVE | 5 CREDIT HOURS SATISFIES FIVE (5) CREDIT HOURS FOR THE PATIENT SAFETY REQUIREMENT

The course begins with an overview of risk management and related issues, emphasizing the need for primary care clinicians to establish risk management strategies in their practice. A definition of tort (personal-injury) law and several legal issues related to malpractice lay the foundation for a better understanding of such key concepts as medical negligence and the standard of care, adequate informed consent, statutes of limitations, and measure of damages. In addition, the course discusses malpractice-related laws such as apology statutes, good Samaritan laws, and charitable immunity laws; knowledge of these laws can help healthcare professionals better protect themselves from malpractice. Descriptions of the common characteristics of malpractice claims and the consequences of malpractice are included to enhance healthcare professionals’ understanding of the underlying causes and motivations of malpractice claims and to improve their ability to handle a malpractice lawsuit. Tort reform is addressed to enable clinicians to become familiar with the proposed solutions to malpractice problems and participate in this national debate. The course closes with a brief discussion of the initial steps involved in responding to a malpractice claim and minimizing loss.

106

FINAL EXAMINATION ANSWER SHEET REQUIRED TO RECEIVE CREDIT

iii

Table 1. MOC Recognition Statements Successful completion of certain enclosed CME activities, which includes participation in the evaluation component, enables the participant to earn up to the amounts and credit types shown in Table 2 below. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit. Board Programs MOC CREDIT INFORMATION Participants can earn MOC points equivalent to the amount of CME credits claimed for designated activities. InforMed currently reports to the following specialty boards: ABA, ABIM, ABS, ABPath and ABP. To be awarded MOC points, you must obtain a passing score, complete the corresponding activity evaluation, and provide required information necessary for reporting.

American Board of Anesthesiology’s redesigned Maintenance of Certification in Anesthesiology TM (MOCA®) program, known as MOCA 2.0®

ABA

ABIM American Board of Internal Medicine’s Maintenance of Certification (MOC) program

ABS American Board of Surgery’s Continuous Certification program

ABPath American Board of Pathology’s Continuing Certification program

ABP American Board of Pediatrics’ Maintenance of Certification (MOC) program

Table 2. Credits and Type Awarded

AMA PRA Category 1 Credits T M

Activity Title

ABA

ABIM ABS

ABPath

ABP

Child Abuse Identification and Reporting: The Pennsylvania Requirement

3 AMA PRA Category 1 Credits TM

3 Credits LL

3 Credits MK

3 Credits SA + AC

3 Credits LL

Opioid Safety: Balancing Benefits and Risks

5 AMA PRA Category 1 Credits TM 5 AMA PRA Category 1 Credits TM 3 AMA PRA Category 1 Credits TM 5 AMA PRA Category 1 Credits TM

5 Credits LL

5 Credits MK

5 Credits SA + AC

5 Credits LL

5 Credits LL + SA

5 Credits LL & PS 3 Credits LL & PS 5 Credits LL & PS

5 Credits MK & PS 3 Credits MK & PS 5 Credits MK & PS

5 Credits SA + AC 3 Credits SA + AC 5 Credits SA + AC

5 Credits LL 3 Credits LL 5 Credits LL

5 Credits LL + SA 3 Credits LL 5 Credits LL + SA

Burnout in Physicians

Falls and Fall Prevention

Risk Management

Legend: LL = Lifelong Learning, MK = Medical Knowledge, SA = Self-Assessment, LL+SA = Lifelong Learning & Self-Assessment, AC = Accredited CME, PS = Patient Safety

DATA REPORTING: Federal, State, and Regulatory Agencies require disclosure of data reporting to all course participants. InforMed abides by each entity’s requirements for data reporting to attest compliance on your behalf. Reported data is governed by each entity’s confidentiality policy. To report compliance on your behalf, it’s mandatory that you must achieve a passing score and accurately fill out the learner information, activity and program evaluation, and the 90-day follow-up survey. Failure to accurately provide this information may result in your data being non-reportable and subject to actions by these entities.

How to complete

Please read these instructions before proceeding. Read and study the enclosed courses and answer the final examination questions. To receive credit for your courses, you must provide your customer information and complete the mandatory evaluation. We offer two ways for you to complete. Choose an option below to receive credit and your certificate of completion.

ONLINE

FASTEST AND EASIEST!

• Go to BOOK.CME.EDU and enter code MDPA2126 in the book code box, then click GO.

Enter book code

• Proceed to your exam. If you already have an account, sign in with your username and password. If you do not have an account, you’ll be able to create one now. • Follow the online instructions to complete your final examination. Complete the purchase process to receive course credit and your certificate of completion. Please remember to complete the online evaluation.

MDPA2126

IF YOU’RE ONLY COMPLETING CERTAIN COURSES IN THIS BOOK: • Go to BOOK.CME.EDU and enter the code that corresponds to the course below, then click GO. Each course will need to be completed individually, and the specified course price will apply.

Complete the answer sheet and evaluation found in the back of this book. Include your payment information and email address. Mail to: InforMed, PO Box 997432, Sacramento, CA 95899

BY MAIL

Mailed completions will be processed within 2 business days of receipt, and certificates emailed to the address provided. Submissions without a valid email address will be mailed to the postal address provided.

EARLY BIRD PRICING SPECIAL!

Program Options

Early Bird Pricing expires 6/30/2026

Price

Option

Code

Credits

$150 ENTIRE PROGRAM (INCLUDES ALL COURSES)

MDPA2126

$40 Child Abuse Identification and Reporting: The Pennsylvania Requirement

MDPA03CA

$50 Opioid Safety: Balancing Benefits and Risks

MDPA05OS

$50 Burnout in Physicians

MDPA05BP

$30 Falls and Fall Prevention

MDPA03FP

$50 Risk Management

MDPA05RM

Note: Prices are subject to change

____________________________ Child Abuse Identification and Reporting: The Pennsylvania Requirement MDPA03CA — 3 CREDIT HOURS R elease D ate : 12/01/24 E xpiration D ate : 11/30/27

Child Abuse Identification and Reporting: The Pennsylvania Requirement This course is approved by the Pennsylvania Department of Human Services to fulfill the requirement for 3 hours of Child Abuse Recognition and Reporting (Act 31) training for healthcare professionals applying for licensure. Provider number CACE000020. This course is approved by the Pennsylvania Department of Human Services to fulfill the requirement for 2 hours of Child Abuse Recognition and Reporting (Act 31) training for healthcare professionals renewing their license. Provider number CACE000020. In addition to receiving AMA PRA Category 1 Credit TM , physicians participating in Maintenance of Certification will receive the following points appropriate to their certifying board: 3 ABIM MOC Points, 3 ABS MOC Points, 3 ABA MOCA Points, 3 ABP MOC Points, 3 ABPath CC Points.

MDPA2126 Mention of commercial products does not indicate endorsement. Alice Yick Flanagan, PhD, MSW , received her Master’s in Social Work from Columbia University, School of Social Work. She has clinical experience in mental health in correc- tional settings, psychiatric hospitals, and community health centers. In 1997, she received her PhD from UCLA, School of Public Policy and Social Research. Dr. Yick Flanagan completed a year-long post-doctoral fellowship at Hunter College, School of Social Work in 1999. In that year she taught the course Research Methods and Violence Against Women to Masters degree students, as well as conducting qualitative research studies on death and dying in Chinese American families. Previously acting as a faculty member at Capella University and Northcentral University, Dr. Yick Flanagan is currently a contributing faculty member at Walden University, School of Social Work, and a dissertation chair at Grand Canyon Uni- versity, College of Doctoral Studies, working with Industrial Organizational Psychology doctoral students. She also serves 6. Identify circumstances under which mandated report- ers are required to make a report if they have reason- able cause to suspect a child is a victim of child abuse. Faculty 3. Outline the action(s) a mandated reporter must imme- diately make if they have reasonable cause to suspect a child is a victim of child abuse, including identification of defining circumstances. 4. Relate the actions that are NOT required to take place in order for a mandated reporter to make a report of suspected child abuse. 5. Describe the concept of good faith and how it relates to a mandated reporter making a report of suspected child abuse.

HOW TO RECEIVE CREDIT

• Read the enclosed course. • Complete the final examination questions at the end. A score of 70% is required. • Return your customer information/answer sheet, evaluation, and payment to InforMed by mail or complete online at BOOK.CME.EDU.

Audience This course is designed for all Pennsylvania physicians, physi- cian assistants, nurses, social workers, counselors, pharmacists, and allied health professionals required to complete child

abuse education. Course Objective

The purpose of this course is to enable healthcare professionals in all practice settings to define child abuse and identify the children who are affected by violence. This course describes how a victim can be accurately diagnosed and identifies the community resources available in the state of Pennsylvania for

child abuse victims. Learning Objectives Upon completion of this course, you should be able to:

1. Identify the basis for reporting suspected child abuse, including having “reasonable cause to suspect” a child is a victim of child abuse. 2. List the three key components of child abuse as defined by the PA CPSL.

Child Abuse Identification and Reporting: The Pennsylvania Requirement _____________________________

as a consultant/subject matter expert for the New York City Board of Education and publishing companies for online cur- riculum development, developing practice MCAT questions in the area of psychology and sociology. Her research focus is on the area of culture and mental health in ethnic minority communities. Faculty Disclosure Contributing faculty, Alice Yick Flanagan, PhD, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Division Planner John M. Leonard, MD Mary Franks, MSN, APRN, FNP-C Margaret Donohue, PhD Randall L. Allen, PharmD Senior Director of Development and Academic Affairs Sarah Campbell Division Planner/Director Disclosure The division planner and director have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Accreditations & Approvals In support of improving patient care, NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Successful completion of this CME activity, which includes participation in the evaluation component, enables the par- ticipant to earn up to 3 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equiva- lent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit par- ticipant completion information to ACCME for the purpose of granting ABIM MOC credit. Completion of this course constitutes permission to share the completion data with ACCME. Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit toward the CME and Self-Assessment requirements of the American Board of Surgery’s Continu- ous Certification program. It is the CME activity provider’s responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit. Successful completion of this CME activity, which includes participation in the activity with individual assessments of the participant and feedback to the participant, enables the participant to earn 3 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC)

program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABP MOC credit. Through an agreement between the Accreditation Council for Continuing Medical Education and the Royal College of Physicians and Surgeons of Canada, medical practitioners participating in the Royal College MOC Program may record completion of accredited activities registered under the ACC- ME’s “CME in Support of MOC” program in Section 3 of the Royal College’s MOC Program. Designations of Credit NetCE designates this enduring material for a maximum of 3 AMA PRA Category 1 Credit(s) ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Special Approvals This course is approved by the Pennsylvania Department of Human Services to fulfill the requirement for 3 hours of Child Abuse Recognition and Reporting (Act 31) training for healthcare professionals applying for licensure. Provider number CACE000020. This course is approved by the Pennsylvania Department of Human Services to fulfill the requirement for 2 hours of Child Abuse Recognition and Reporting (Act 31) training for healthcare professionals renewing their license. Provider number CACE000020. About the Sponsor The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare. Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice. Disclosure Statement It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distrib- uting or providing access to this activity to learners.

Sections marked with this symbol include evidence-based practice recommendations. The level of evidence and/or strength of recommendation, as provided by the evidence-based source, are also included

so you may determine the validity or relevance of the information. These sections may be used in conjunction with the course material for better application to your daily practice.

MDPA2126

____________________________ Child Abuse Identification and Reporting: The Pennsylvania Requirement

each county agency for child abuse cases. Cases identified as CPS require an investigation because the alleged act or failure to act meets the definition of child abuse. The PA CPSL’s definition of child abuse recognizes 10 separate categories of child abuse. Examples of CPS cases include: • Causing bodily injury to a child through any recent act or failure to act • Fabricating, feigning or intentionally exaggerating or inducing a medical symptom or disease which results in a potentially harmful medical evaluation or treatment to the child through any recent act • Causing or substantially contributing to serious mental injury to a child through any act or failure to act or a series of such acts or failures to act • Causing sexual abuse or exploitation of a child through any act or failure to act • Creating a reasonable likelihood of bodily injury to a child through any recent act or failure to act • Creating a likelihood of sexual abuse or exploitation of a child through any recent act or failure to act • Causing serious physical neglect of a child • Engaging in a specific recent “per se” act • Causing the death of the child through any act or failure to act • Engaging a child in a severe form of trafficking in per- sons or sex trafficking GENERAL PROTECTIVE SERVICES GPS is involved in non-abuse cases or acts that involve non- serious injury or neglect [38]. The primary purpose of GPS is to protect the rights and welfare of children, so they have an opportunity for healthy growth and development [38]. It includes services and activities provided by each county agency for cases requiring protective services, as defined by DHS in regulations. GPS cases require an assessment for services and supports. In these cases, the alleged act or failure to act may not meet the definition of child abuse but is still detrimental to a child. Examples of GPS cases: services are provided to prevent the potential for harm to a child who meets one of the following conditions: • Is without proper parental care or control, subsistence, education as required by law, or other care or control necessary for their physical, mental, or emotional health, or morals • Has been placed for care or adoption in violation of law • Has been abandoned by their parents, guardian, or other custodian • Is without a parent, guardian, or legal custodian • Is habitually and without justification truant from school while subject to compulsory school attendance

CHILD WELFARE IN PENNSYLVANIA Pennsylvania was also the first state to take a noncriminal view of child abuse [22; 26]. In 1975, the Pennsylvania Child Protective Services Law (CPSL) (23 Pa.C.S. Chapter 63, Child Protective Services was enacted, which established a child abuse hotline and a statewide central registry in Pennsylvania in order to encourage the reporting of child abuse [26]. The purpose of the Law is to protect children from abuse, allow the opportunity for healthy growth and development, and preserve and stabilize the family whenever possible. It does not restrict the generally recognized existing rights of parents to use rea- sonable supervision and control when raising their children. The child welfare system in Pennsylvania is supervised by the state but administered by the different local counties [27]. This means that there are a total of 67 county agencies that administer the child welfare and juvenile justice services [27]. The State of Pennsylvania delineates two functions for the local agencies: child protective services (CPS) and general protective services (GPS). Recent amendments to the PA CPSL relevant to child abuse recognition and reporting include Act 115 of 2016 (relating to human trafficking), Act 54 of 2018 (relating to notification of substance affected infants by healthcare providers and plan of safe care), and Act 88 of 2019 (relating to penalties for failure to report or refer). In 2016, SB1311 (Act 115) was signed and went into effect. This Act provides for additional grounds for involuntary termi- nation of parental rights, provides for an additional grounds for aggravated circumstances, allows for the release of information in confidential reports to law enforcement when investigating cases of severe forms of trafficking in persons of sex trafficking, and adds a category of child abuse to include human trafficking. In 2017, Governor Tom Wolf approved Act 68 (also known as the Newborn Protection Act) to increase the number of loca- tions for parents to give up their newborn without criminal liability [6]. In 2018, Act 29 was signed and expanded the definition of child abuse in Pennsylvania to include leaving a child unsupervised with a sexual predator [5]. That same year, Act 54 was signed and required mandatory notification when a medical provider has determined that a child (younger than 1 year of age) was born affected by substance use or withdrawal symptoms resulting from prenatal drug or alcohol exposure. This Act also mandates the development of “interagency pro- tocols” to support local multidisciplinary teams to identify, assess, and develop a plan of safe care for infants born affected by substance use or withdrawal symptoms. In 2019, Act 88, relating to penalties for failure to report or refer, was enacted. CHILD PROTECTIVE SERVICES The Pennsylvania child welfare system is state-supervised and county-administered. County children-and-youth agencies (CCYAs) have two main functions: Child Protective Services (CPS) and General Protective Services (GPS). The first is CPS, which consists of services and activities provided by DHS and

MDPA2126

Child Abuse Identification and Reporting: The Pennsylvania Requirement _____________________________

• Has committed a specific act of habitual disobedience of the reasonable and lawful commands of their parent, guardian, or other custodian and who is ungovernable and found to be in need of care, treatment, or supervi- sion • Is younger than 10 years of age and has committed a delinquent act • Has been formerly adjudicated dependent under sec- tion 6341 of the Juvenile Act (relating to adjudication) and is under the jurisdiction of the court, subject to its conditions or placements, and who commits an act that is defined as ungovernable • Has been referred under section 6323 of the Juvenile Act (relating to informal adjustment) and who commits an act that is defined as ungovernable DEFINITIONS OF CHILD ABUSE In Pennsylvania, the child abuse law takes a very comprehensive approach to defining of child abuse [26]. According to Penn- sylvania law, child abuse shall mean intentionally, knowingly, or recklessly doing any of the following [13]: • Causing bodily injury to a child through any recent act or failure to act • Fabricating, feigning, or intentionally exaggerating or inducing a medical symptom or disease that results in a potentially harmful medical evaluation or treatment to the child through any recent act • Causing or substantially contributing to serious mental injury to a child through any act or failure to act or a series of such acts or failures to act • Causing sexual abuse or exploitation of a child through any act or failure to act • Creating a reasonable likelihood of bodily injury to a child through any recent act or failure to act • Creating a likelihood of sexual abuse or exploitation of a child through any recent act or failure to act • Causing serious physical neglect of a child • Engaging in any of the following specific recent “per se” acts: – Kicking, biting, throwing, burning, stabbing, or cutting a child in a manner that endangers the child – Unreasonably restraining or confining a child, based on consideration of the method, location, or duration of the restraint or confinement – Forcefully shaking a child younger than 1 year of age – Forcefully slapping or otherwise striking a child younger than 1 year of age

– Interfering with the breathing of a child – Causing a child to be present at a location while a violation of 18 Pa.C.S. § 7508.2 relating to the operation of methamphetamine laboratory is occurring, provided that the violation is being investigated by law enforcement – Leaving a child unsupervised with an individual, other than the child’s parent, who the actor knows or reasonably should have known a) is required to register as a Tier II or Tier III sex- ual offender (under 42 Pa.C.S. Ch. 97 Subch. H relating to registration of sexual offenders), where the victim of the sexual offense was younger than 18 years of age when the crime was committed; b) has been determined to be a sexually violent predator (under 42 Pa.C.S. § 9799.24 relating to assessments, or any of its predecessors); has been determined to be a sexually violent delinquent child (as defined in 42 Pa.C.S. § 9799.12 relating to definitions); or d) has been determined to be a sexually violent c) predator (under 42 Pa.C.S. § 9799.58, relating to assessments) or has to register for life (under 42 Pa.C.S. § 9799.55(b) relating to registration) • Causing the death of the child through any act or failure to act • Engaging a child in a severe form of trafficking in per- sons or sex trafficking, as those terms are defined under section 103 of the Trafficking Victims Protection Act of 2000 KEY COMPONENTS OF CHILD ABUSE • Child: An individual younger than 18 years of age • Act or failure to act; Recent act; Recent act or failure to act; or A series of acts or failures to act – Act: Something that is done to harm or cause potential harm to a child – Failure to act: Something that is NOT done to prevent harm or potential harm to a child – Recent act: Any act committed within two (2) years of the date of the report to DHS or county agency – Recent act or failure to act: Any act or failure to act committed within two (2) years of the date of the report to DHS or county agency • Intentionally, knowingly, or recklessly – Intentionally: Done with the direct purpose of causing the type of harm that resulted – Knowingly: Awareness that harm is practically certain to result – Recklessly: Conscious disregard of substantial and unjustifiable risk

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____________________________ Child Abuse Identification and Reporting: The Pennsylvania Requirement

EXCLUSIONS In addition, the CPSL explicitly excludes specific acts and injuries from the definition of child abuse: • Restatement of culpability: Conduct that causes injury or harm to a child or creates a risk of injury or harm to a child shall not be considered child abuse if there is no evidence that the person acted intentionally, knowingly, or recklessly when causing the injury or harm to the child or creating a risk of injury or harm to the child. • Child abuse exclusions: The term child abuse does not include any conduct for which an exclusion is provided in § 6304 of the PA CPSL (relating to exclusions from child abuse). Exclusions to the definition of child abuse (23 Pa.C.S. § 6304): • Environmental factors: No child shall be deemed to be physically or mentally abused based on injuries that result solely from environmental factors, such as inadequate housing, furnishings, income, clothing, and medical care, that are beyond the control of the parent or person responsible for the child’s welfare with whom the child resides. This shall not apply to any child-care service as defined under section 6303(a) of the PA CPSL (excluding an adoptive parent). • Practice of religious beliefs: If, upon investigation, the county agency determines that a child has not been provided needed medical or surgical care because of sincerely held religious beliefs of the child’s parents or relative within the third degree of consanguinity and with whom the child resides, which beliefs are consis- tent with those of a bona fide religion, the child shall not be deemed to be physically or mentally abused. In such cases the following shall apply: – The county agency shall closely monitor the child and the child’s family and shall seek court-ordered medical intervention when the lack of medical or surgical care threatens the child’s life or long-term health. – All correspondence with a subject of the report and the records of the department and the county agency shall not reference child abuse and shall acknowledge the religious basis for the child’s condition. – The family shall be referred for general protective services, if appropriate. – This exclusion shall not apply if the failure to provide needed medical or surgical care causes the death of the child. – This exclusion shall not apply to any childcare service as defined under section 6303(a) of the PA CPSL (excluding an adoptive parent).

• Use of force for supervision, control, and safety pur- poses: Subject to subsection (d) (relating to the rights of parents), the use of reasonable force on or against a child by the child’s own parent or person responsible for the child’s welfare shall not be considered child abuse if any of the following conditions apply: – The use of reasonable force constitutes incidental, minor, or reasonable physical contact with the child or other actions that are designed to main- tain order and control. – The use of reasonable force is necessary to quell a disturbance or remove the child from the scene of a disturbance that threatens physical injury to per- sons or damage to property; to prevent the child from self-inflicted physical harm; for self-defense or the defense of another individual; or to obtain possession of weapons or other dangerous objects or controlled substances or paraphernalia that are on the child or within the control of the child. • Rights of parents: Nothing in this chapter shall be con- strued to restrict the generally recognized existing rights of parents to use reasonable force on or against their children for the purposes of supervision, control, and discipline of their children. Such reasonable force shall not constitute child abuse. • Participation in events that involve physical contact with child: An individual participating in a practice or competition in an interscholastic sport, physical educa- tion, recreational activity, or extracurricular activity that involves physical contact with a child does not, in itself, constitute contact that is subject to the reporting requirements of the PA CPSL. • Defensive force: Reasonable force for self-defense or the defense of another individual shall not be considered child abuse. – Reasonable force for self-defense or the defense of another individual (consistent with the provisions of 18 Pa.C.S. § 505, relating to use of force in self-protection, and § 506 (relating to use of force for the protection of other persons) shall not be considered child abuse. • Child-on-child contact: – Harm or injury to a child that results from the act of another child shall not constitute child abuse unless the child who caused the harm or injury is a perpetrator. – Notwithstanding paragraph (1) above, the follow- ing shall apply:  Acts constituting any of the following crimes against a child shall be subject to the reporting requirements of the PA CPSL:

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Child Abuse Identification and Reporting: The Pennsylvania Requirement _____________________________

– Rape (as defined in 18 Pa.C.S. § 3121, relating to rape) – Involuntary deviate sexual intercourse (as defined in 18 Pa.C.S. § 3123, relating to involuntary deviate sexual intercourse) – Sexual assault (as defined in 18 Pa.C.S. § 3124.1, relating to sexual assault) – Aggravated indecent assault (as defined in 18 Pa.C.S. § 3125, relating to aggravated indecent assault) – Indecent assault (as defined in 18 Pa.C.S. § 3126, relating to indecent assault), and indecent exposure (as defined in 18 Pa.C.S. § 3127, relating to indecent expo- sure)  No child shall be deemed to be a perpetrator of child abuse based solely on physical or mental injuries caused to another child in the course of a dispute, fight, or scuffle entered into by mutual consent.  A law enforcement official who receives a report of suspected child abuse is not required to make a report to the department if the person allegedly responsible for the child abuse is a nonperpetrator child. Nothing in the CPSL requires a person who has reasonable cause to suspect a child is a victim of child abuse to consider the exclusions from child abuse before making a report of suspected child abuse; the exclusions from child abuse are considered/determined by DHS or the investigating agency after receipt of a referral/report. PERPETRATOR For the purposes of this course, a perpetrator is defined as an individual who has committed child abuse as defined under section 6303(b.1) of the Child Protective Services Law. The term includes only [2; 13]: • A parent of the child • A spouse or former spouse of the child’s parent • A paramour or former paramour of the child’s parent • A person 14 years of age or older responsible for the child’s welfare or having direct contact with children as an employee of childcare services, a school, or through a program, activity, or service • An individual 14 years of age or older who resides in the same home as the child • An individual 18 years of age or older who does not reside in the same home as the child but is related within the third degree of consanguinity or affinity by birth or adoption to the child

• An individual 18 years of age or older who engages a child in severe forms of trafficking in persons or sex trafficking, as those terms are defined under section 103 of the Trafficking Victims Protection Act of 2000 In a significant revision to the definition of perpetrator, school personnel and other childcare providers are consid- ered “individuals responsible for the child’s welfare” and may be perpetrators of child abuse; there is no longer a separate definition for student abuse [2]. As such, a perpetrator may be any such person who has direct or regular contact with a child through any program, activity, or services sponsored by a school, for-profit organization, or religious or other not-for- profit organization. In addition, only the following may be considered a perpetrator for failing to act [2; 13]: • A parent of the child • A spouse or former spouse of the child’s parent • A paramour or former paramour of the child’s parent • A person 18 years of age or older and responsible for the child’s welfare or who resides in the same home as the child Nothing under Pennsylvania law requires a person who has reasonable cause to suspect a child is a victim of child abuse to identify the person responsible for the child abuse in order to make a report of suspected child abuse. FORMS OF CHILD ABUSE There are several acts that may be considered abusive, and knowledge of what constitutes abuse is vital for healthcare providers and other mandated reporters. In this section, specific behaviors that fall under the category of abuse and neglect will be reviewed. Bodily Injury Bodily injury can range from minor bruises and lacerations to severe neurologic trauma and death. Bodily injury is one of the most easily identifiable forms of abuse and the type most commonly seen by healthcare professionals [34]. Definitions (23 Pa.C.S. § 6303) The following words and phrases, when used in the PA CPSL, shall have the meanings given to them in this section unless the context clearly indicates otherwise: • Bodily injury: Impairment of physical condition or substantial pain – Impairment: If, due to the injury, the child’s ability to function is reduced temporarily or permanently in any way – Substantial pain: If the child experiences what a reasonable person believes to be substantial pain

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____________________________ Child Abuse Identification and Reporting: The Pennsylvania Requirement

Sexual Abuse/Exploitation Definitions (23 Pa.C.S. § 6303) Sexual abuse or exploitation includes any of the following [45]: • The employment, use, persuasion, inducement, enticement, or coercion of a child to engage in or assist another individual to engage in sexually explicit conduct, which includes, but is not limited to, the fol- lowing: – Looking at the sexual or other intimate parts of a child or another individual for the purpose of arousing or gratifying sexual desire in any indi- vidual – Participating in sexually explicit conversation either in person, by telephone, by computer, or by a computer-aided device for the purpose of sexual stimulation or gratification of any individual – Actual or simulated sexual activity or nudity for the purpose of sexual stimulation or gratification of any individual – Actual or simulated sexual activity for the purpose of producing visual depiction, including photo- graphing, videotaping, computer depicting, or filming The above does not include consensual activities between a child who is 14 years of age or older and another person who is 14 years of age or older and whose age is within 4 years of the child’s age. • Any of the following when committed against a child: – Rape (as defined in 18 Pa.C.S. § 3121, relating to rape) – Statutory sexual assault (as defined in 18 Pa.C.S. § 3122.1, relating to statutory sexual assault) – Involuntary deviate sexual intercourse (as defined in 18 Pa.C.S. § 3123, relating to involuntary devi- ate sexual intercourse) – Sexual assault (as defined in 18 Pa.C.S. § 3124.1, relating to sexual assault) – Institutional sexual assault (as defined in 18 Pa.C.S. § 3124.2, relating to institutional sexual assault) – Aggravated indecent assault (as defined in 18 Pa.C.S. § 3125, relating to aggravated indecent assault) – Indecent assault (as defined in 18 Pa.C.S. § 3126, relating to indecent assault)

Indicators of bodily injury include: • Fear of going home • Fear of parent or caregiver

• Extreme apprehensiveness/vigilance • Pronounced aggression or passivity • Flinches easily or avoids being touched • Play includes abusive talk or behavior • Unexplained injuries

• Unbelievable or inconsistent explanations of injuries • Injuries inconsistent with a child’s age/developmental level • Unable to recall how injuries occurred or account of injuries is inconsistent with the nature of the injuries • Multiple bruises in various stages of healing • Bruises located on face, ears, neck, buttocks, back, chest, thighs, back of legs, and genitalia • Bruises that resemble objects such as a hand, fist, belt buckle, or rope • Burns Fractures that result from abuse might be found on the child’s skull, ribs, nose, or any facial structure. These may be multiple or spiral fractures at various stages of healing. When examining patients, note bruises on the abdominal wall, any intestinal perforation, ruptured liver or spleen, and blood vessel, kidney, bladder, or pancreatic injury, especially if accounts for the cause do not make sense. Look for signs of abrasions on the child’s wrists, ankles, neck, or torso. Lacerations might also appear on the child’s lips, ears, eyes, mouth, or genitalia. If violent shaking or trauma occurred, the child might experience a subdural hematoma [9; 34].

According to the American College of Radiology, fractures highly suggestive of physical abuse include rib fractures, classic metaphyseal lesions, those unsuspected or inconsistent with the history or age of the child, multiple fractures involving more

than one skeletal area, and fractures of differing ages. (https://acsearch.acr.org/docs/69443/Narrative. Last accessed December 9, 2024.) Level of Evidence : Expert Opinion/Consensus Statement

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Child Abuse Identification and Reporting: The Pennsylvania Requirement _____________________________

– Indecent exposure (as defined in 18 Pa.C.S. § 3127, relating to indecent exposure) – Incest (as defined in 18 Pa.C.S. § 4302, relating to incest) – Prostitution (as defined in 18 Pa.C.S. § 5902, relat- ing to prostitution and related offenses) – Sexual abuse (as defined in 18 Pa.C.S. § 6312, relating to sexual abuse of children) – Unlawful contact with a minor (as defined in 18 Pa.C.S. § 6318, relating to unlawful contact with minor) – Sexual exploitation (as defined in 18 Pa.C.S. § 6320, relating to sexual exploitation of children) Indicators of sexual abuse or exploitation include: • Sexually promiscuous behavior • Developmental age-inappropriate sexual play and/or drawings • Cruelty to others • Cruelty to animals • Fire setting • Anxious • Withdrawn • Sleep disturbances • Bedwetting • Pain or irritation in genital/anal area • Difficulty walking or sitting • Difficulty urinating • Pregnancy • Positive testing for sexually transmitted infection(s) (e.g., HIV) • Excessive or injurious masturbation

Indicators of serious physical neglect include: • Not registered in school • Inadequate or inappropriate supervision • Poor impulse control • Frequently fatigued • Parentified behaviors • Lack of adequate medical and dental care

• Often hungry • Lack of shelter • Weight is significantly lower than normal for their age and gender • Developmental delays • Persistent (untreated) conditions (e.g., head lice, diaper rash) • Exposure to hazards (e.g., illegal drugs, rodent/insect infestation, mold) • Clothing that is dirty, inappropriate for the weather, too small, or too large

Serious Mental Injury Definitions (23 Pa.C.S. § 6303)

Serious mental injury is a psychological condition, as diagnosed by a physician or licensed psychologist, including the refusal of appropriate treatment, that [1]: • Renders a child chronically and severely anxious, agitated, depressed, socially withdrawn, psychotic, or in reasonable fear that the child’s life or safety is threat- ened; or • Seriously interferes with a child’s ability to accomplish age-appropriate developmental and social tasks Indicators of serious mental injury include: • Expressing feelings of inadequacy • Fearful of trying new things • Overly compliant • Poor peer relationships • Excessive dependence on adults • Habit disorders (e.g., sucking, rocking) • Eating disorders • Frequent psychosomatic complaints (e.g., nausea, stom- achache, headache) • Bed-wetting • Self-harm • Speech disorders

Serious Physical Neglect Definitions (23 Pa.C.S. § 6303)

Pennsylvania law defines serious physical neglect of a child as any of the following when committed by a perpetrator that endangers a child’s life or health, threatens a child’s well-being, causes bodily injury, or impairs a child’s health, development, or functioning: • A repeated, prolonged, or egregious failure to supervise a child in a manner that is appropriate considering the child’s developmental age and abilities • The failure to provide a child with adequate essentials of life, including food, shelter, or medical care

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____________________________ Child Abuse Identification and Reporting: The Pennsylvania Requirement

Severe Forms of Trafficking in Persons Severe forms of trafficking in persons: • Sex trafficking in which a commercial sex act is induced by force, fraud, or coercion or in which the person induced to perform such act has not attained 18 years of age; or – Sex trafficking: the recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purpose of a com- mercial sex act  Commercial sex act: Any sex act on account of which anything of value is given to or received by any person • The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion, for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery. Examples include: – Peonage: Paying off debt through work – Debt bondage: Debt slavery, bonded labor, or services for a debt or other obligation – Slavery: A condition compared to that of a slave in respect of exhausting labor or restricted freedom Labor trafficking is labor obtained by use of threat of serious harm, physical restraint, or abuse of legal process. Examples include: • Being forced to work for little or no pay (frequently in factories and farms) • Domestic servitude, defined as providing services within a household for 10 to 16 hours per day, such as, but not limited to, childcare, cooking, cleaning, yard work, and gardening Victim Identification/Warning Signs (Human Trafficking [Act 115 of 2016]) Warning signs specifically associated with victims of child traf- ficking and/or exploitation include (but are not limited to): • A youth that has been verified to be younger than 18 years of age and is in any way involved in the com- mercial sex industry or has a record of prior arrest for prostitution or related charges • An explicitly sexual online profile • Excessive frequenting of Internet chat rooms or classi- fied sites • Depicting elements of sexual exploitation in drawing, poetry, or other modes of creative expression • Frequent or multiple sexually transmitted infections or pregnancies • Is found in a hotel, street track, truck stop, or strip club

• Lies about or has no identification or knowledge of personal data, such as but not limited to: age, name, and/or date of birth • Wearing clothing that is dirty, sexually inappropriate, inappropriate for the weather, or too large or too small (often dresses or skirts that are provocative in nature) • Wearing new clothes of any style, getting hair and/or nails done with no financial means • Having multiple cell phones or very expensive items that they have no way of purchasing on their own • Having unaddressed medical issues or goes to the ER or clinic alone or with an unrelated adult

• Being secretive about whereabouts • Having late nights or unusual hours

• Having a tattoo that s/he is reluctant to explain • Being in a controlling or dominating relationship • Lack of insurance or control of own finances • Exhibiting hypervigilance or paranoid behaviors • Expressing interest in or being in relationships with adults or much older men or women • Avoiding answering questions and letting someone else speak for them • Having significant change in behavior, including increased social media and new associates or friends at school • Having unexplained injuries and/or unbelievable or inconsistent explanations of injuries • Having multiple bruises or cuts in various stages of healing • Using specific terms, such as “trick,” “the life,” or “the game” With this in mind, it is important not to stigmatize children based on their gender expression and clothing choices. At-Risk Youth Populations (Human Trafficking [Act 115 of 2016]) At-risk youth populations include, but are not limited to, youth [7]: • In the foster care system • Who identify as LGBTQIA+ • Who are homeless or runaway • With disabilities • With mental health or substance abuse disorders • With a history of sexual abuse • With a history of being involved in the welfare system • Who identify as native or aboriginal • With family dysfunction

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