Pennsylvania Code
Title 55 - HUMAN SERVICES
Part VIII - Intellectual Disability and Autism Manual
Subpart A - Statements of Policy
Chapter 6000 - STATEMENTS OF POLICY
Subchapter R - PROCEDURES FOR SURROGATE HEALTH CARE DECISION MAKING
STATUTES
Appendix E - INCIDENT MANAGEMENT COMPONENTS
PROVIDERS/ENTITIES ARE TO:
* Promote the health, safety, rights and enhance the dignity of individuals receiving services.
* Develop provider-specific policy/procedures for incident management.
* Ensure that staff and others associated with the individual have proper orientation and training to respond to, report and prevent incidents.
* Provide ongoing training to individuals and families on the recognition of abuse and neglect.
* Ensure when incidents occur that affect a person's health, safety or rights, that the people who are present:
- Take prompt action to protect the person's health, safety and rights. This includes separation of the target when the individual's health and safety are jeopardized. This separation shall continue until an investigation is completed. In addition, the target shall not be permitted to work directly with any other service recipient during the investigation process. When the target is another individual receiving supports or services, and complete separation is not possible, the provider shall institute additional protections.
- Notify the responsible person designated in provider policy.
* Assign trained individual(s) Point Person(s) to whom incidents are reported when they occur and who will make certain that all immediate steps to assure health and safety have been implemented and follow the incident through closure.
* Contact appropriate law enforcement agencies when there is suspicion that a crime has occurred.
* Comply with all applicable laws, regulations and policies.
* Conduct certified investigations.
* Analyze the quality of investigations.
* Respond to concerns from individuals/family about the reporting and investigation processes.
* Inform the family of the incident unless otherwise indicated in the individual's plan.
* Notify the family of the findings of any investigation unless otherwise indicated in the individual's plan.
* Maintain an investigation file within the agency.
* Create an incident management process which:
- Designates an individual with overall responsibility for incident management.
- Considers possible immediate and long-term effects to the individual resulting from an incident or multiple incidents.
- Uses trend analyses to identify systemic issues.
- Analyzes and shares information with relevant staff, including direct care staff.
- Periodically assesses the effectiveness of the incident management process.
- Monitors quality and responsiveness of all ancillary services (such as health, therapies, etc.) and acts to change vendors or subcontractors, or assists the individual to file available grievances or appeals procedures to secure appropriate services.
COUNTIES ARE TO:
* Promote the health, safety, rights and dignity of individuals receiving services.
* Develop county policies and procedures necessary to implement this bulletin.
* Have an administrative structure sufficient to meet mandates of this bulletin:
- Designate an individual with overall responsibility for incident management.
- Train staff in incident management procedures.
- Assure that supports coordinators have proper orientation and training to respond to, document and prevent incidents.
- Support providers with appropriate training and resources to meet the mandates of the bulletin.
* Provide ongoing training to individuals, families, guardians, and advocates regarding their rights, roles and responsibilities that are outlined in this bulletin.
* Provide training to individuals and families on the recognition of abuse and neglect.
* Have the Incident Management Processes in this bulletin referenced in county/provider contracts.
* Maintain an investigation file within the county.
* Create an incident management process which:
- Assures accuracy of incident reports.
- Reviews and closes all provider generated incidents.
- Reviews and analyzes data.
- Identifies and implements individual and systemic changes based on data analysis.
- Analyzes and shares information with relevant staff.
- Regularly reviews trend and occurrence data compiled by providers.
- Assesses provider's incident management and investigative processes.
- Assures provider compliance with plans of correction resulting from incidents and investigations.
* Conduct certified investigations.
* Analyze the quality of investigations.
* Respond to concerns from individuals/family about the reporting and investigation processes.
* In collaboration with the individual's planning team, revise the individual's plan as needed in response to issues identified through the incident management process.
* Comply with all applicable laws, regulations and policies.
* Coordinate with other agencies as necessary.
* In those instances where the county is the initial reporter of the incident, the county will assume the responsibility of the point person.
THE OFFICE OF MENTAL RETARDATION IS TO:
* Promote the health, safety, rights and dignity of individuals receiving services.
* Create an incident management review process which:
- Maintains the statewide data system.
- Analyzes data for statewide trends and issues.
- Identifies issues and initiates systemic changes and provides periodic feedback.
- Evaluates county and provider reports and analysis of trends.
* Monitor implementation of this bulletin.
* Support providers and counties with appropriate training to meet the mandate of the bulletin.
* Certify investigators.
* Provide support and technical assistance to counties to implement the incident reporting system.
* Conduct certified investigations.
* Analyze the quality of investigations.
* Respond to concerns from individuals/families about the reporting and investigation processes.
* Review and revise this bulletin as needed.
* Ensure compliance with all applicable laws, regulations and policies.
* Coordinate with other agencies as necessary.
This appendix cited in 55 Pa. Code § 6000.902 (relating to purpose).
