Compilation of Rules and Regulations of the State of Georgia
Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH
Chapter 111-8 - HEALTHCARE FACILITY REGULATION
Subject 111-8-37 - RULE AND REGULATIONS FOR HOSPICES
Rule 111-8-37-.06 - Reports to the Department

Universal Citation: GA Rules and Regs r 111-8-37-.06

Current through Rules and Regulations filed through September 23, 2024

(1) Patient Incidents Requiring Report. The hospice must report to the Department, on forms made available by the Department, within 24 hours or the next business day, whenever any of the following incidents involving patients occurs or the hospice has reasonable cause to believe that an incident involving a patient has occurred:

(a) Any death of a hospice patient not related to the natural course of the patient's terminal illness or advanced and progressive disease, or any identified underlying condition;

(b) Any rape, assault, or any abuse, neglect or exploitation of a patient; and

(c) Any time a patient, who is admitted to a residential or inpatient hospice facility cannot be located, where there are circumstances that place the health, safety, or welfare of the patient or others at risk and the patient has been missing for more than eight hours.

(2) Where the hospice staff has reasonable cause to believe that a disabled adult or elder person has been the victim of abuse, other than by accidental means, or has been neglected or exploited, the hospice must report such information to an adult protection agency providing protective services as designated by the Department and to an appropriate law enforcement agency or prosecuting attorney.

(3) The hospice, through its peer review committee, must submit the reports of patient incidents listed in subparagraph (1)(a) through (c) of this rule. The Department will receive and retain such peer review reports concerning the listed incidents in confidence.

(4) Reports of patient incidents made through the peer review process must include:

(a) The name of the hospice, the name of the administrator or site manager, and a contact telephone number for information related to the report;

(b) The date of the incident and the date the hospice became aware of the incident;

(c) The type of incident, with a brief description of the incident; and

(d) Any immediate corrective or preventative action taken by the hospice to ensure against the replication of the incident.

(5) The hospice must conduct an internal investigation of any of the patient incidents listed in subparagraph (1)(a) through (c) and must complete and retain on-site a written report of the results of the investigation within 45 days of the discovery of the incident. The complete report must be made available to the Department for inspection at the hospice office and contain at least:

(a) An explanation of the circumstances surrounding the incident, including the results of a root cause analysis or any other detailed system analysis;

(b) Any findings or conclusions associated with the review; and

(c) A summary of any actions taken to correct identified problems associated with the incident and to prevent recurrence of the incident, and also any changes in procedures or practices resulting from the investigation.

(6) The hospice must report to the Department any pending involuntary discharge of a hospice patient initiated by the hospice. The report must be made no later than the time of notification to the patient of the pending discharge.

(7) Other Events Requiring Report.

(a) The hospice must report in an acceptable format to the Department whenever any of the following events involving hospice operations occur or when the hospice becomes aware that any such events are likely to occur, to the extent that such events are expected to cause or cause a significant disruption of care for hospice patients:
1.An external disaster or other community emergency situation; or

2.An interruption of services vital to the continued safe operation of a hospice facility, such as telephone, electricity, gas, or water services.

(b) The hospice must make a report of the event within twenty-four hours or by the next regular business day from when the reportable event occurred or from when the hospice has reasonable cause to anticipate that the event is likely to occur. The report must include:
1.The name of the hospice, the name of the hospice administrator or site manager, and a contact telephone number for information related to the report;

2.The date of the event, or the anticipated date of the event, and the anticipated duration, if known;

3.The anticipated effect on care and services for hospice patients; and

4.Any immediate plans the hospice has made regarding patient management during the event.

(c) Within 45 days of the discovery of the event, the hospice must complete an internal evaluation of the hospice's response to the event where opportunities for improvement related to the hospice's disaster preparedness plan were identified. The hospice must make changes to the disaster preparedness plan as appropriate. The complete report must be available to the Department for inspection at the hospice office.

(8) While self-reported incidents made through the hospice's peer review process are received by the Department in confidence and not considered open records, where the Department's internal review determines that a rule violation related to any self-reported incident or event has occurred, the Department shall initiate a separate complaint investigation of the incident. The complaint investigation report and the report of any rule violation compiled by the Department arising either from the initial report received from the hospice or an independent source shall be subject to disclosure in accordance with applicable laws.

O.C.G.A. §§ 31-7-130et seq., 31-7-170et seq.

Disclaimer: These regulations may not be the most recent version. Georgia may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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