New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIII - Office of Mental Health
Part 524 - Incident Management Programs
Section 524.8 - Incident reporting procedures

Universal Citation: 14 NY Comp Codes Rules and Regs ยง 524.8

Current through Register Vol. 46, No. 39, September 25, 2024

Incident management programs shall include procedures for promptly reporting incidents consistent with the following:

(a) Reportable Incidents identified in Section 524.7(a) and (b) of this Part that must be reported to the Justice Center and the Office must be made in accordance with the following, provided, however, that nothing in this Section shall be deemed to prohibit a Mandated Reporter from contacting or reporting to law enforcement or emergency services before or after making a report to the Vulnerable Persons' Central Register.

(1) Justice Center. Employees of mental health providers who are Mandated Reporters, must immediately make a report of a Reportable Incident to the Justice Center's Vulnerable Persons' Central Register, upon discovery of what appears to be a Reportable Incident.
(i) The report to the Register shall include the name, title, and contact information of every person known to the Mandated Reporter to have the same information as the Mandated Reporter concerning the incident.

(ii) If the reportable incident is a death for which there is any reason to believe that abuse or neglect may be involved, the Mandated Reporter must immediately contact the Justice Center's Vulnerable Persons' Central Register 24/7 Hotline and provide all information requested by the Justice Center, to the best of his/her ability.

(iii) The Mandated Reporter must immediately notify the director of the mental health provider, or his//her designee, that a report has been made.

(iv) An initial incident report in the form and format specified by the Justice Center shall be completed within 24 hours of discovery.

(v) The Justice Center has the statutory authority to investigate allegations of abuse or neglect and significant incidents. A mental health provider and its employees are required to cooperate fully with the Justice Center regarding such investigations, including but not limited to providing access at any and all times to all patients, staff, and any facility building, room or place or part thereof and to all books, records, and data pertaining to such program's patients, staff, facility or part thereof. All relevant records and reports shall be made available, upon request, to investigators at any point following the report of the incident. Patients, employees and any other persons may be interviewed in conjunction with any such investigation.

(2) Office of Mental Health. Mental health providers are responsible for immediately notifying the Office of Reportable Incidents within 24 hours of occurrence or discovery, whichever occurs first.
(i) Such notification shall be in a form or format specified by the Office, and shall include such information as is known at the time the form is completed.

(ii) The Office has the statutory authority to investigate all incidents. A mental health provider and its employees are required to cooperate fully with the Office regarding such investigations, including but not limited to providing access at any and all times to all patients, staff, and any facility building, room or place or part thereof and to all books, records, and data pertaining to such program's patients, staff, facility or part thereof. All relevant records and reports shall be made available, upon request, to investigators at any point following the report of the incident. Patients, employees and any other persons may be interviewed in conjunction with any such investigation.

(b) If, at any point in an investigation, facts are discovered that suggest an incident should be reclassified (e.g., facts are discovered indicating a significant incident must be upgraded to abuse or neglect), all reports applicable to the revised incident type must be made.

(c) Nothing in this Part shall be deemed to supersede the obligation of providers licensed or administered by the Office to directly report crimes to the district attorney or law enforcement and the Office when it appears that a crime may have been committed against a person receiving services, pursuant to Section 31.11 of the Mental Hygiene Law.

(d) Nothing in this Part shall be deemed to preclude providers from identifying other incident types, not required to be reported and investigated pursuant to this Part, that may be investigated, monitored, and analyzed pursuant to internal quality management procedures.

(e) In cases where multiple mandated reporters have direct knowledge of the same reportable incident or have reasonable cause to suspect such incident has occurred, each mandated reporter is required to report such incident, unless he or she knows that the report has already been made by another mandated reporter and that he or she has been named in that report as a person with knowledge of such incident. Providers shall establish written protocols to ensure reports involving multiple mandated reporters are properly made and documented.

(f) The Office shall develop protocols in consultation with the Justice Center to assist providers in appropriately and therapeutically responding in circumstances where patients have a demonstrated pattern of frequently reporting allegations of abuse or neglect that are not reasonably reliable (i.e., there is no possibility that an allegation is true).

(g) The Office shall identify a standard process to be used by providers by which incident reporting and management notifications, alerts, and any other correspondence necessary for the timely follow up of reportable events are received and organized.

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