New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIV - Office for People With Developmental Disabilities
Part 624 - Reportable Incidents And Notable Occurrences
Section 624.7 - Incident Review Committee (IRC)

Universal Citation: 14 NY Comp Codes Rules and Regs § 624.7

Current through Register Vol. 47, No. 12, March 26, 2025

(a) Every agency must have one or more incident review committees to review and monitor reportable incidents and notable occurrences that occur to people receiving services from the agency The agency's organizational structure and its own policies will determine the number of committees needed.

(b) An IRC must review reportable incidents and notable occurrences to:

(1) ascertain that reportable incidents and notable occurrences were reported, managed, investigated, and documented consistent with the provisions of this Part and with agency policies and procedures, and to make written recommendations to the appropriate staff and/or the chief executive officer to correct, improve, or eliminate inconsistencies;

(2) ascertain that necessary and appropriate corrective, preventive, remedial, and/or disciplinary action has been taken to protect persons receiving services from further harm, to safeguard against the recurrence of similar reportable incidents and notable occurrences, and to make written recommendations to the chief executive officer to correct, improve, or eliminate inconsistencies;

(3) ascertain if further investigation or if additional corrective, preventive, remedial, and/or disciplinary action is necessary, and if so, to make appropriate written recommendations to the chief executive officer relative to the reportable incident or notable occurrence;

(4) identify trends in reportable incidents and notable occurrences (e.g., by type, person, site, employee involvement, time, date, circumstances, etc.), and to recommend appropriate corrective, preventive, remedial, and/or disciplinary action to the chief executive officer to safeguard against such recurring situations or reportable incidents and notable occurrences; and

(5) ascertain and ensure the adequacy of the agency's reporting and review practices, including the monitoring of the implementation of approved recommendations for corrective, preventive, and remedial action.

(c) An IRC must:

(1) meet as determined by agency policy, but no less frequently than on a quarterly basis and always within one month of the report of a reportable incident or serious notable occurrence, or sooner should the circumstances so warrant. The IRC shall meet as necessary to meet the timeframes established for submission of a final report to the Justice Center for reportable incidents, if required;

(2) review and monitor all minor notable occurrences that are reported, which may be done by a sub-committee of the IRC or by individual assignment to members of the IRC, and maintain a record of such incident/occurrence review, recommendations, and/or actions taken in such a manner as to provide for tracking and trending;

(3) review and monitor all reportable incidents and/or serious notable occurrences that are reported;

(4) review and monitor investigatory procedures, but shall not perform the routine investigation of reportable incidents or notable occurrences;

(5) make written recommendations to appropriate staff to eliminate or minimize similar reportable incidents and/or notable occurrences in the future, and/or to improve investigatory or other procedures;

(6) make written recommendations to the chief executive officer on changes in agency policy or procedures and to improve conditions contributing to the reportable incidents and/or notable occurrences reviewed;

(7) forward findings and recommendations to the chief executive officer within two weeks of meeting;

(8) provide documentation that all reports of reportable incidents and serious notable occurrences have been reviewed by the committee and that results and recommendations have been conveyed to appropriate agency executives and others with a need to know;

(9) monitor actions taken on any and all recommendations made and advise the chief executive officer when there is a problem;

(10) monitor trends of other events or situations attributable to a person receiving services which may be potentially harmful, but do not meet the definition of being a reportable incident or notable occurrence (see subdivision 624.2(e)). This may be done by the full committee or a member of a subcommittee reporting to the full committee;

(11) in accordance with agency policy, report periodically, but at least annually, to the chief executive officer, chief agency executives, the governing body, and OPWDD concerning the committee's general monitoring functions; general identified trends in reportable incidents and notable occurrences; and corrective, preventive, remedial and/or disciplinary action pertaining to identified trends; and

(12) interact with the governing body and comply with the policies in relation to the review and monitoring of all reportable incidents and notable occurrences.

(d) For reportable incidents of abuse and neglect in facilities and programs that are certified or operated by OPWDD, an incident will not be considered closed by an IRC until the agency receives written notification from the Justice Center which specifies that it has accepted an investigation conducted by the agency (or by OPWDD) or, if the Justice Center conducted the investigation, when the Justice Center notifies the agency that the incident is closed.

Note: The Justice Center may amend findings made by an agency or OPWDD. Findings made by the Justice Center are considered final.

(e) Role of the IRC when investigations are conducted by the Central Office of OPWDD or the Justice Center. Notwithstanding any other provision of this Part, when an investigation of an incident or occurrence is conducted by the Central Office of OPWDD or the Justice Center:

(1) The IRC role in reviewing and monitoring the particular incident or occurrence is limited to matters involving compliance with the reporting and notification requirements of this Part, protective and remedial actions taken (except disciplinary actions concerning services operated by OPWDD), operational concerns, and the quality of services provided.

(2) The finding (of the report of abuse or neglect) of substantiated or unsubstantiated must be made by the Central Office of OPWDD or the Justice Center.

(3) Concerning services operated by OPWDD:
(i) The IRC must monitor all actions taken to implement recommendations made by the Central Office of OPWDD or the Justice Center, except recommendations for disciplinary action.

(ii) The IRC for state-operated services must not review or monitor disciplinary action recommendations made by the Central Office of OPWDD or the Justice Center.

(4) Concerning facilities and programs that are not operated by OPWDD, including non-certified programs and programs certified under section 16.03 (a)(4) or 16.03 (a)(5) of the Mental Hygiene Law, the IRC must monitor all actions taken to implement recommendations made by the Central Office of OPWDD or the Justice Center.

(f) Organization and membership of the IRC.

(1) A committee or committees may be established to meet the organizational needs of an agency (e.g., on an agency-wide basis, for a certified class of facilities, for a grouping of certified classes of facilities, by types of services provided, etc.). An agency may establish its own committee or committees and/or may meet the requirements of this section in several other ways, either concerning all operations of the committee or for specific incidents/occurrences or types of incidents/occurrences.
(i) An agency may coordinate with other agencies in the establishment of a shared committee.

(ii) An agency may also coordinate with a different agency to use the other agency's IRC.

(iii) An alternate acceptable committee review arrangement may be established with the approval of OPWDD.

(2) Committee members must be appointed by the chief executive officer. In the case of a shared committee, each chief executive officer must appoint committee members and approve the shared committee membership arrangement.

(3) An IRC may have other responsibilities in addition to specified responsibilities related to reportable incidents and notable occurrences.

(4) Membership of an IRC must include:
(i) except for state-operated services, a member of the governing body;

(ii) for state-operated services, a high-level administrator (note: this cannot be the Director);

(iii) at least two professional staff, including but not limited to, licensed clinicians, such as occupational, physical, and speech therapists, social workers, psychologists, and nurses; a behavioral intervention specialist (BIS, see subdivision 633.16(b)); and others with primary responsibility for developing and/or monitoring individuals' plans of care, such as developmental and habilitation specialists or a QIDP. At least one of the professional staff must be a licensed health care practitioner (e.g. physician, physician's assistant, nurse practitioner, or registered nurse).

(iv) other staff, including administrative staff, as deemed necessary by the agency to achieve the purposes of the committee pursuant to this section;

(v) at least one direct support professional (except for agencies that do not have direct support professionals);

(vi) at least one individual receiving services;

(vii) at least one representative of advocacy organizations (e.g. self-advocacy, family, or other advocacy organizations); and

(viii) the participation of a psychologist on the committee is recommended.

(5) In the event that an agency is unable to obtain the members required by subparagraphs (i) and (v) - (viii), the agency must document its periodic efforts to obtain the specified members.

(6) Membership limitations.
(i) The chief executive officer of the agency must not serve as a member of the committee, but may be consulted by the committee in its deliberations.

(ii) The administrator of a class or classes of facilities or a group or groups of services may be designated as a member only if the committee is an agency-wide or multi-program committee. If he or she is not a member, an administrator may be consulted by the committee in its deliberations.

(7) Case-specific requirements.
(i) There must be representation by someone from or with knowledge of the program or service within the agency where the event under discussion occurred, or by someone who is familiar with the person(s) involved.

(ii) Restrictions on review of specific incidents or allegations of abuse.
(a) Any committee member who recognizes a potential conflict of interest in his or her assignment must report this information to the committee and recuse him or herself from participating in committee review of the incident or occurrence in question.

(b) No committee member may participate in the review of any reportable incident or notable occurrence in which he or she was directly involved, in which his or her testimony is incorporated, in which his or her spouse, domestic partner, or other immediate family member was directly involved, or which he or she investigated or participated in the investigation. Such members may, however, participate in committee deliberation regarding appropriate corrective, preventive, or remedial action.

(c) For reportable incidents and serious notable occurrences, no committee member may participate in the review of an investigation in which his or her spouse, domestic partner, or immediate family member provides supervision to the program where the incident took place or supervised directly involved parties.

(d) No committee member may participate in the review of a reportable incident or serious notable occurrence, if such committee member is the immediate supervisor of staff directly involved in the event or situation. Such member may, however, participate in committee deliberation regarding appropriate corrective, preventive, or remedial action.

(8) Members of the committee must be trained in confidentiality laws and regulations, and shall comply with section 74 of the public officers law.

(g) Minutes. The chairperson of an incident review committee must ensure that minutes are kept for all meetings.

(1) For reportable incidents and serious notable occurrences, the portion of the minutes that discuss matters concerning the specific event or situation must be entered into IRMA within three weeks of the meeting.

(2) Minutes addressing the review of specific reportable incidents and/or serious notable occurrences must clearly state the filing number or identification code of the report (if used), the person's full name and identification number (if used), and provide a brief summary of the situation (including date, location, and type) that caused the report to be generated, committee findings (including reclassification of event, if applicable), and recommendations and actions taken on the part of the agency as a result of such recommendations. Full names of all parties involved must be recorded (not initials).

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