New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XXI - OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES
Part 836 - Incident Reporting in Oasas Certified, Licensed, Funded, or Operated Services
Section 836.6 - Incident reporting, notice, and investigations in facilities and provider agencies certified, licensed or operated by the Office

Universal Citation: 14 NY Comp Codes Rules and Regs § 836.6

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

(a) Unless otherwise indicated herein, all reportable incidents as defined in this Part shall be reported to the Vulnerable Persons' Register.

(b) A custodian of any service provider who personally observes, is advised of, or otherwise becomes aware of an incident must take immediate and appropriate action to intervene and attempt to prevent or limit injury or potential injury to any person to the greatest extent possible.

(c) In accordance with a provider's incident management program, a written incident report must be initiated or a call made by a mandated reporter as defined in this Part to the Vulnerable Persons' Register toll-free hotline immediately after a reportable incident is discovered.

(1) Every mandated reporter who has direct knowledge of an incident and has reasonable cause to suspect that a person receiving services has been subjected to a reportable incident is required to make a report to the VPCR unless:

(i) he or she has actual knowledge that the reportable incident has been reported to the VPCR; and

(ii) that he or she has been named as a person with knowledge of the incident in such prior report.

(2) For purposes of this reporting obligation, "discovery" occurs when a mandated reporter has "reasonable cause to suspect" that a service recipient has been subjected to a reportable incident. This may occur either:

(i) when a mandated reporter witnesses a suspected reportable incident; or

(ii) when another person, including a service recipient, comes before the mandated reporter, in the mandated reporter's professional or official capacity, and provides the mandated reporter with reasonable cause to suspect that a service recipient has been subjected to a reportable incident.

(3) For purposes of this reporting obligation, "reasonable cause to suspect" does not require conclusive evidence that the incident occurred; a rational or sensible suspicion is sufficient and may be based on the mandated reporter's observations, training and experience, and the mandated reporter's disbelief of an explanation provided for an injury.

(d) In addition to those reports of reportable incidents that must be made to the Justice Center, an initial incident report must be forwarded to the director or designee for investigation immediately after an incident is discovered. Such an initial incident report shall, at a minimum, contain the following information:

(1) The exact date and time of the incident if known; and

(2) a description of the incident, including location, and actions taken in response to it; and

(3) the name(s), address(es), and telephone number(s) of the victim(s), witness(es), and any other persons involved; and

(4) the presence of injuries, if any, and first aid provided to address such injuries.

(e) The Justice Center shall determine whether a reportable incident shall be investigated by the Justice Center or delegated to the Office for investigation. If an incident is delegated to the Office by the Justice Center, the Office may investigate such reportable incident itself, or may delegate such an investigation to the facility or provider agency. For any investigation of a reportable incident of abuse or neglect that is not conducted by the Justice Center, the final report of such investigation of abuse or neglect must be provided to the Justice Center no later than fifty (50) days after the Justice Center accepts the initial report of the incident, unless an extension of time is granted for documented good cause. Any final report of a delegated significant incident must be provided to the Justice Center within sixty (60) days after the Justice Center accepts the initial report of the incident, unless an extension of time is granted for documented good cause.

(f) All incidents must be recorded by the service provider and all incident reports and other relevant records made available for inspection by the Office and the Justice Center, when appropriate.

(g) Upon notice to the Office, service providers may delay "discovery," as such term is defined in paragraph (2) of subdivision (c) of this section, and immediate reporting for no more than twenty-four (24) hours in order to conduct a preliminary review of an allegation of abuse or neglect under circumstances in which:

(1) the person making the allegation of abuse or neglect has a documented history of making false reports of abuse or neglect and no other person has come forward as a witness to such allegation; or

(2) the person making the allegation of abuse or neglect has a documented behavioral or psychological condition that would tend to cause such person to make a false report of abuse or neglect and no other person has come forward as a witness to such allegation.

(h) Any delayed discovery of an allegation pursuant to subdivision (g) of this section must be documented, such documentation including:

(1) the reasons identified above for such delay in any subsequent report to the Justice Center; or

(2) the basis for a determination not to report; such documentation shall be available to the Justice Center or the Office upon request.

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