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Ohio Administrative Code (Last Updated: January 12, 2021) |
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5122 Department of Mental Health - Administration and Director |
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Chapter5122-26. Policies and Procedures for the Operation of Mental Health Services Agencies |
5122-26-13. Incident notification and risk management
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(A) This rule establishes standards to ensure the prompt and accurate notification of certain prescribed incidents. It also requires the provider to review and analyze all incidents so that it might identify and implement corrective measures designed to prevent recurrence and manage risk.
(B) Definitions
(1) "County community board of residence" means the board that is responsible for referring or paying for the client's treatment.
(2) "County community board" means a board with which the provider has entered into a contract to provide services or facilities.
(3) "Incident" means an event that poses a danger to the health and safety of clients or staff and visitors of the provider, and is not consistent with routine care of persons served or routine operation of the provider.
(4) "Reportable Incident" means an incident that must be submitted to the department. As referenced in division (E) of section 5119.36 of the Revised Code, "Major Unusual Incident" has the same meaning as "Reportable Incident."
(5) "Six month reportable incident" means an incident type of which limited information must be reported to the department. A six month reportable incident is not the same as a reportable incident.
(6) "Six month incident data report" means a data report which must be submitted to the department.
(C) The provider shall develop an incident reporting system to include a mechanism for the review and analysis of all reportable incidents such that clinical and administrative activities are undertaken to identify, evaluate, and reduce risk to clients, staff, and visitors. The provider shall identify in policy other incidents to be reviewed and analyzed.
(1) An incident report shall be submitted in written form to the provider's executive director or designee within twenty-four hours of discovery of a reportable incident.
(2) As part of the provider's performance improvement process, a periodic review and analysis of reportable incidents, and other incidents as defined in the provider's policy, shall be performed. This shall include a review of all incident reports received from class two and class three residential facilities as defined in division (B) of section 5119.34 of the Revised Code regarding persons served by the provider, and any action taken by the provider, as appropriate.
(3) The provider shall maintain an ongoing log of its reportable incidents for departmental review.
(D) Any person who has knowledge of any instance of abuse or neglect, or alleged or suspected abuse or neglect of:
(1) Any child or adolescent, shall immediately notify the county children's services board, the designated child protective agency, or law enforcement authorities, in accordance with section 2151.421 of the Revised Code; or
(2) An adult age sixty and over, shall immediately notify the appropriate county department of jobs and family services authorities in accordance with section 5101.63 of the Revised Code.
(E) Each provider shall submit reportable incidents and six month reportable incidents as defined by and according to the schedule included in appendix A to this rule.
(F) Each reportable incident shall be documented as required by the department. The information shall include identifying information about the provider, date, time and type of incident, and client information that has been de-identified pursuant to the HIPAA privacy regulations, [ 45 C.F.R. 164.514(b)(2) ], and 42 CFR Part B, paragraph 2.22., if applicable.
(1) The provider shall file only one incident form per event occurrence and identify each incident report category, if more than one, and include information regarding all involved clients, staff, and visitors.
If, after submitting a reportable incident to the department, a provider learns that an additional incident report category in addition to that which was already submitted is associated with the same event occurrence, the provider shall either amend the original report or submit a new incident report including only the new incident category and information.
(2) The provider shall forward each reportable incident to the department and to the county community board of residence within twenty-four hours of its discovery, exclusive of weekends and holidays.
(G) Each provider shall submit a six month incident data report to the department and to the county community board utilizing the form that is in appendix B to this rule.
The six month incident data report must be submitted according to the following schedule:
(1) The six month incident data report for the period of January first through June thirtieth of each year shall be submitted no later than July thirty-first of the same year; and
(2) The six month incident data report for the period of July first through December thirty-first of each year shall be submitted no later than January thirty-first of the following year.
(H) The department may initiate follow-up and further investigation of a reportable incident and six month reportable incidents, as deemed necessary and appropriate, or may request such follow-up and investigation by the provider, regulatory or enforcement authority, or the county community board.