Current through Register Vol. 39, No. 12, December 1, 2024
(a) Category A and B providers shall develop
and implement written policies governing their response to level I, II or III
incidents. The policies shall require the provider to respond by:
(1) attending to the health and safety needs
of individuals involved in the incident;
(2) determining the cause of the
incident;
(3) developing and
implementing corrective measures according to provider specified timeframes not
to exceed 45 days;
(4) developing
and implementing measures to prevent similar incidents according to provider
specified timeframes not to exceed 45 days;
(5) assigning person(s) to be responsible for
implementation of the corrections and preventive measures;
(6) adhering to confidentiality requirements
set forth in G.S. 75, Article 2A, 10A NCAC 26B, 42 CFR Parts 2 and 3 and 45 CFR
Parts 160 and 164; and
(7)
maintaining documentation regarding Subparagraphs (a)(1) through (a)(6) of this
Rule.
(b) In addition to
the requirements set forth in Paragraph (a) of this Rule, ICF/MR providers
shall address incidents as required by the federal regulations in 42 CFR Part
483 Subpart I.
(c) In addition to
the requirements set forth in Paragraph (a) of this Rule, Category A and B
providers, excluding ICF/MR providers, shall develop and implement written
policies governing their response to a level III incident that occurs while the
provider is delivering a billable service or while the client is on the
provider's premises. The policies shall require the provider to respond by:
(1) immediately securing the client record
by:
(A) obtaining the client record;
(B) making a photocopy;
(C) certifying the copy's completeness;
and
(D) transferring the copy to an
internal review team;
(2) convening a meeting of an internal review
team within 24 hours of the incident. The internal review team shall consist of
individuals who were not involved in the incident and who were not responsible
for the client's direct care or with direct professional oversight of the
client's services at the time of the incident. The internal review team shall
complete all of the activities as follows:
(A)
review the copy of the client record to determine the facts and causes of the
incident and make recommendations for minimizing the occurrence of future
incidents;
(B) gather other
information needed;
(C) issue
written preliminary findings of fact within five working days of the incident.
The preliminary findings of fact shall be sent to the LME in whose catchment
area the provider is located and to the LME where the client resides, if
different; and
(D) issue a final
written report signed by the owner within three months of the incident. The
final report shall be sent to the LME in whose catchment area the provider is
located and to the LME where the client resides, if different. The final
written report shall address the issues identified by the internal review team,
shall include all public documents pertinent to the incident, and shall make
recommendations for minimizing the occurrence of future incidents. If all
documents needed for the report are not available within three months of the
incident, the LME may give the provider an extension of up to three months to
submit the final report; and
(3) immediately notifying the following:
(A) the LME responsible for the catchment
area where the services are provided pursuant to Rule .0604;
(B) the LME where the client resides, if
different;
(C) the provider agency
with responsibility for maintaining and updating the client's treatment plan,
if different from the reporting provider;
(D) the Department;
(E) the client's legal guardian, as
applicable; and
(F) any other
authorities required by law.
Authority
G.S.
122C-112.1;
143B-139.1;
Temporary Adoption Eff. July 1, 2003;
Eff. July 1,
2004;
Amended Eff. August 1, 2009;
Pursuant to
G.S.
150B-21.3A, rule is necessary without
substantive public interest Eff. July 20,
2019.
