New Mexico Administrative Code
Title 7 - HEALTH
Chapter 20 - MENTAL HEALTH
Part 11 - CERTIFICATION REQUIREMENTS FOR CHILD AND ADOLESCENT MENTAL HEALTH SERVICES
Section 7.20.11.17 - ALLEGATIONS OF ABUSE/NEGLECT, COMPLAINTS, AND SERIOUS INCIDENT REPORTING

A. The agency maintains and follows policies and procedures consistent with these certification requirements for timely reporting of any serious incidents and allegations of abuse or neglect. The agency immediately reports allegations of abuse or neglect to all appropriate entities, including but not limited to the protective services division of the department via statewide ventral intake/tribal social services agency, the client's legal guardian, the jurisdictional law enforcement agency, and the LCA.

B. The agency reports all serious incidents to the LCA by fax within 24 hours of any staff member becoming aware of the incident or allegation of incident. Incidents involving minor illnesses or injuries not requiring emergency services do not need to be reported to the LCA. Day treatment services, case management services, and behavioral management skills development services are not required to report serious incidents that do not occur during program hours, with the exception that all deaths must be reported.

C. Additional reporting requirements for deaths: Deaths are reported to the LCA immediately by telephone and followed by fax within 24 hours, whether or not the death occurs during program hours. Agencies are required to report any client death to the regional office of the federal centers for medicare and medicaid services by no later than by the close of business the next business day after the client's death, and must document in the client's record that the death was reported to the centers for medicare and medicaid services.

D. Each serious incident report is written by the staff who have personal or firsthand knowledge of the incident/allegation, and is signed and dated by that person(s). Once written, the report is not altered, but may be amended. Any amendment is signed and dated by its author and filed with the original report. The report clearly distinguishes between events witnessed by the reporter and statements made to the reporter. The report contains, but is not limited to the following information regarding the incident: date, time, and location of the incident, behavioral description(s) of relevant event(s), descriptions of health/safety risk(s) relevant to the incident, identification of person(s) present, birth date(s) of client(s) involved, level of care of the client(s) involved, initial actions in response to the incident, names of persons providing information to the reporter, and identification of other entities receiving the report.

E. Each serious incident for which a report to the LCA is required herein and that involves possible criminal activity is reported immediately to the appropriate law enforcement agency.

F. The agency responds in a timely manner to protect its clients from physical or psychological risks of which it is or reasonably should be aware, in order to reduce and prevent future risks.

G. Outcomes, dispositions, and descriptions of any voluntary corrective action(s) taken by the agency in response to serious incidents are faxed or mailed to the LCA in a timely manner.

H. The program will not rely on the fact that it has made a serious incident report to the LCA, or the fact that it may not have received a response from the LCA, to delay appropriate corrective or protective action in response to an incident.

I. The agency maintains and follows policies and procedures for investigating and responding to allegations of abuse or neglect in a confidential and timely manner.

J. The agency maintains and follows policies and procedures for investigating and responding to complaints in a timely manner.

K. The agency provides a written response, in a timely manner, to the complaining party and, as applicable, the parent, legal or treatment guardian, regarding the resolution of each complaint or allegation.