Current through Register Vol. 46, No. 39, September 25, 2024
(a) The governing authority of every facility
or provider agency certified, licensed, funded, or operated by the Office must
establish and maintain written policies and procedures constituting an incident
management program for responding to, reporting, investigating and evaluating
incidents. All incident management programs are subject to review by the Office
and must be consistent with patient rights provisions of Part 815 of this Title
and with the requirements of the Justice Center.
(b) At a minimum, an incident management
program must be consistent with Justice Center Incident Reporting regulations
and incorporate the following:
(1)
identification of staff responsible for administration of the incident
management program;
(2) provisions
for annual review by the governing authority;
(3) specific internal recording and reporting
procedures applicable to all incidents observed, discovered or
alleged;
(4) procedures for
monitoring overall effectiveness of the incident management program;
(5) minimum standards for investigation of
incidents observed, discovered or alleged, including, but not limited to:
(i) physical or medical examination, as
indicated by circumstances; name of examiner; written findings;
(ii) identification and interviews with any
witnesses (interviews conducted separately by qualified, objective persons);
written documentation of such interviews;
(iii) review of pertinent physical evidence;
documentation (photos, expert assessments) and retention by facility Incident
Review Committee, facility executive or other appropriate person;
(iv) documentation of investigative steps
taken.
(6) procedures
for the implementation of corrective action plans if required;
(7) establishment of an Incident Review
Committee pursuant to subdivision (f) of this section;
(8) required periodic training in mandated
reporting obligations of custodians and the Justice Center code of conduct, in
addition to any other training as may be required by the Office and consistent
with Justice Center regulations;
(9) provision for retention of records,
review and release pursuant to Justice center regulations and section 33.25 of the mental hygiene law.
(c) Any provider of services
dually certified, licensed, funded, or operated by the Office and another New
York State agency may substitute the other agency's required incident reporting
program for the requirements of this section provided such program meets or
exceeds the scope and requirements of this Part and such substitution has been
previously approved by the Office and is consistent with Justice Center
regulations. As a condition of such approval, a provider must comply with any
other provisions relevant to incidents as required by the Office and have a
current operating certificate that is not subject to any limitations.
(d) Upon admission to a program, clients, and
others when appropriate and subject to applicable confidentiality laws, must be
informed that a program maintains an incident management program.
(e) Upon clearance for employment any
custodian must be informed of the service provider's incident management
program, custodian obligations as a mandated reporter, and an original signed
attestation by such custodian that they have received and understand such
obligations. Custodian attestation to receiving and understanding the Code of
Conduct must be renewed annually.
(f) Incident Review Committee. Each
provider's incident management program must provide for the establishment of an
Incident Review Committee. Such committee may also perform other review
functions for the facility or service provider, including but not limited to,
quality improvement and/or utilization review, however minimum requirements
include, but are not limited to:
(1) Each
Incident Review Committee must include members of the governing body of the
provider agency and other persons identified by the director, including members
from the following: direct support staff, licensed health care practitioners,
service recipients and representatives of family, consumer and other advocacy
organizations (if appropriate, based on the size of the facility or provider
agency, the Office may authorize an exemption from this requirement or portions
of this requirement upon review of a written request). The executive director
of a provider may not serve as an incident review committee member.
(2) Services not requiring medical staff may
substitute a Qualified Health Professional for the medical staff.
(3) In a service co-located within a general
hospital or a certified hospital for mental illness, or a service that is part
of a larger human services agency, the functions of the Incident Review
Committee may be performed by a hospital-wide committee or an agency-wide
committee, provided a representative from the chemical dependence or compulsive
gambling unit serves on the committee and confidentiality is maintained
pursuant to 42 CFR Part 2, and the functions of the committee meet or exceed
the requirements of this Part.
(4)
Members of the committee shall be trained in confidentiality laws and
regulations and shall comply with section 74 of the Public Officers Law (code of
ethics).
(5) Committee functions
and responsibilities. At a minimum, each Incident Review Committee must:
(i) review and evaluate all
incidents;
(ii) determine the
facts, review and evaluate ongoing practices and procedures in relation to such
incidents, and recommend any indicated changes in practices and procedures to
improve the provider's response to all incidents;
(iii) determine whether there are patterns or
common causes of incidents and make recommendations for changes to prevent
recurrence;
(iv) meet as often as
necessary to properly execute its functions, but in no event less than
quarterly;
(v) keep written minutes
of its deliberations and submit bi-annual reports to the governing
authority;
(vi) prepare a summary
of incidents reviewed and recommendations made, if any, at each meeting;
and
(vii) take any action necessary
to follow up on recommendations made.
(6) Incident Review Committees are
responsible for reviewing individual incidents and incident patterns to
determine the timeliness, thoroughness and appropriateness of the program's
response. The committee may make recommendations to the governing body
regarding the implementation of any preventive or corrective action.
(7) Incident Review Committees are
responsible for monitoring the compliance of the program's incident management
practices and the implementation of any corrective action taken by the
provider. Any corrective action required must be endorsed, in writing, by the
facility director or his/her designee, identify a monitoring date and person
responsible for assessing the efficacy of the corrective action.
(8) The Incident Review Committee must
quarterly compile a collective report of the total number of incidents by type,
its findings and recommendation; such reports shall be maintained by the
governing authority to be available for inspection or review by the Office for
purposes of recertification or by the Justice Center for such purposes as it
may designate.
