New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIII - Office of Mental Health
Part 524 - Incident Management Programs
Section 524.9 - Incident investigation, corrective action, and records maintenance
Universal Citation: 14 NY Comp Codes Rules and Regs ยง 524.9
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Care and Safety of a Patient Involved in an incident: Directors of mental health providers or their designees must ensure that their incident management programs require any staff person who observes or is informed that a Reportable Incident of any type has occurred to immediately provide assistance and secure appropriate care for the involved patient or patients. Such Directors shall provide the Office with contact information for administrators who can be contacted by the Office at any time, on a 24 hour per day, 7 day a week basis, for the purpose of ensuring that such measures have been taken.
(1) If an allegation of abuse or assault has
been made, appropriate care shall include separating the
alleged perpetrator from the alleged victim, in circumstances where it appears
the allegation is credible and sufficient staff coverage can otherwise be
maintained. In all cases, the welfare of the patient is paramount.
(2) Reasonable actions must be taken to
ensure that a patient who has been harmed receives necessary treatment or care.
If a patient has been injured, such actions shall include a medical examination
commensurate with the acuity of the injury. The name of the examiner, the
written findings of the examiner, and a copy of any other medical record
associated with such examination shall be retained by the mental health
provider.
(3) In addition, mental
health providers shall review their activities in response to reportable
incidents to ensure that corrective actions will be taken as necessary to
address systems and personnel issues that may pose a continued risk to
individuals in care.
(b) Documentation. Incident management programs shall include procedures for documenting the occurrence of incidents and the results of all related examinations, investigations and reviews. Incident-related documents are confidential quality assurance documents which shall be maintained separately from the patient's clinical record. However, a description of any clinical impact which an incident may have on a patient shall be recorded in the clinical record.
(c) Investigation Process. Investigations conducted by the Office and mental health providers shall be governed by the provisions of this subdivision.
(1) All incidents shall be
thoroughly investigated in a timely manner by staff competent in investigative
techniques. All investigations and inspections of clinical records shall be
made by persons competent to conduct such investigations and
inspections.
(2) Investigating
entity:
(i) The Justice Center has the
authority to investigate allegations of abuse or neglect and significant
Incidents. It may delegate authority for doing so to the Office.
(ii) The Office may delegate responsibility
for investigating an incident to the mental health provider.
(3) Restrictions.
(i) No one may conduct the investigation of
any Reportable Incident in which he or she was directly involved, or in which
his or her testimony has been incorporated, or in which a spouse, domestic
partner, or immediate family member was directly involved.
(ii) No party in the line of supervision of
staff who were directly involved in a Reportable Incident may conduct the
investigation, provided, however, the director of the mental health provider
may conduct the investigation if he or she is not an immediate supervisor of
any staff who were directly involved in such incident.
(4) Commencing the investigation. As soon as
a provider of services is made aware that an allegation of abuse or neglect has
been reported to the Justice Center, or a patient death has occurred, such
provider is responsible for immediately conducting any assessment or review
that may be necessary, provided, however, that witness statements shall not be
taken by anyone other than the investigating entity designated in accordance
with paragraph (2) of this subdivision. If the Justice Center or the Office
subsequently assumes responsibility for the investigation, the provider must
identify the initial investigatory steps that have been taken and supply any
and all preliminary information it has obtained.
(5) Process. The investigation process shall
be conducted in accordance with guidelines of the Office and shall include the
following components, which must be implemented commensurate with the type and
severity of the incident:
(i)
Preservation of Evidence
(a)
Where there is physical evidence of an incident, it should be preserved
whenever possible, maintaining a chain of possession. For example, if a patient
is injured, bloodied clothing or linens should be saved, labeled as to date,
time, and location where found, and the identity of all persons who handled the
item recorded, until such time as any investigation and any disciplinary action
is completed. Directors of mental health providers shall be responsible for
ensuring secure storage space for such evidence is available.
(b) If the incident is an allegation of
physical abuse, photographs should be taken to document evidence of injury, or
lack thereof.
(c) Any written
documents potentially associated with the incident shall be collected and
safeguarded as soon as the incident is reported or discovered, to ensure that
they are not altered or lost. Such documents may include, but are not limited
to, patients' charts, staff assignment logs, incident reports, and
shift-to-shift communication books.
(ii)
Interviewing Witnesses
(a) Potential witnesses to an incident, which
may include patients, shall be interviewed by persons qualified to conduct such
interviews. Interviews should be conducted separately and as privately as
possible.
(b) Each potential
witness should be asked appropriate questions in an effort to gather pertinent
information about the incident. Where possible, investigators should take into
consideration any apparent issues which may impact an individual's manner of
communication, such as culture, English proficiency, nature of disability,
acuity of illness, etc. Before interviewing patients who are children, consent
from the child's parent or guardian should be obtained if in the best interest
of the child. Children should also be given the option of having clinical
support in the room with them as long as it is not someone who may also be
interviewed in the course of the investigation or asked to provide a witness
statement.
(iii)
Analysis of Evidence. To the extent possible, all available
information pertinent to the incident shall be reviewed. Examples of such
information may include, but are not limited to, photographs or videos, the
alleged site/location of the incident, records and documents of the mental
health provider, witness statements, records or documents from external
assessments or surveys, and/or records of similar previous incidents.
(d) Final Reports.
(1) Abuse and Neglect. The
results of an incident investigation shall be summarized in a written final
investigative report. The purpose of such report is to describe the methods and
procedures used in conducting the investigation, summarize the interviews and
other evidence collected, outline the factual theories considered, explain the
preliminary findings and conclusions reached (with reference to the supporting
information obtained in the investigation), identify concerns, and provide
recommendations with respect to substantiating or unsubstantiating the
allegations.
(2) Incidents reported
to the Justice Center and the Office. For all Significant Incidents that were
accepted by the Vulnerable Persons' Central Register, providers of mental
health services shall submit investigative findings to the Office, which shall
submit them to the Justice Center.
(3) Incidents reported only to the Office.
For those incidents which are only reported to the Office in accordance with
Section
524.10(b)
of this Part, providers of mental health services shall submit investigative
findings to the Office.
(4)
Submission of reports or investigative findings:
(i) Final reports and investigative findings
for Reportable Incidents must be submitted in the manner, form, and format
specified by the Justice Center and the Office.
(ii) Abuse and Neglect. Final reports must be
submitted to the Office within 45 calendar days of the Vulnerable Persons'
Central Register acceptance of a report of an allegation of abuse or
neglect.
(iii) Significant
Incidents. Investigative findings must be submitted to the Office within 45
calendar days of acceptance by the Vulnerable Persons' Central Register of a
report of a Significant Incident.
(5) If the Justice Center or the Office
conducts an investigation of a licensed provider of mental health services,
such provider is not required to submit a final investigative report or
investigative findings to the Justice Center.
(i) If the Office conducts the investigation,
the Office shall submit the final report or investigative findings to the
Justice Center, as required, provided, however, that the provider of mental
health services shall supply information as requested by the Justice Center or
the Office as may be necessary for the completion of the final investigative
report or investigative findings.
(ii) If a provider of mental health services
has conducted an investigation of a Significant Incident delegated to it by the
Office, the Office shall submit investigative findings to the Justice Center,
consistent with guidance issued by the Office.
(e) Confidentiality. All documents, reports, and information obtained in the course of the investigation are confidential and shall not be used or disclosed except as authorized by federal or state laws and regulations. Such documents, records, and information shall be maintained so as to protect the privacy of patients, anyone involved in a reportable incident, or others whose names appear in the report or whose identity in the report is otherwise easy to ascertain.
Disclaimer: These regulations may not be the most recent version. New York 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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