5122-26-13 Incident notification and risk management.

 

 

 

5122-26-13                  Incident notification.

 

 

 

(A)This rule establishes standards to ensure the prompt and accurate notification of certain prescribed incidents. It also requires the agency 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)"Incident" means any event that poses a danger to the health and safety of clients and/or staff and visitors of the agency, and is not consistent with routine care of persons served or routine operation of the agency.

 

(2)"Reportable Incident" means an incident that must be submitted to the department and to the mental health board, including incidents that must then be forwarded by the department to the Ohio legal rights service pursuant to section 5123.604 of the Revised Code. Reportable incidents are those that involve clients and shall include deaths, serious bodily injuries, alleged criminal acts, alleged abuse or neglect, any adverse reaction of a client to a life threatening degree due to an administered drug, medication errors likely to result in serious consequences to a client, and any life threatening situations. As referenced in division (C) of section 5119.611 of the Revised Code, "Major Unusual Incident" has the same meaning as "Reportable Incident".

 

 

(C)The agency shall develop an incident reporting system to include a mechanism for the review and analysis of all incidents such that clinical and administrative activities are undertaken to identify, evaluate, and reduce risk to clients, staff, and visitors.

 

(1)An incident report shall be submitted in written form to the agency's executive director or designee within twenty-four hours of discovery of the incident.

 

(2)As part of the agency's performance improvement process, a periodic review and analysis of incidents shall be performed. This shall include a review of all incident reports received from licensed type 2 and type 3 residential facilities regarding persons served by the agency, and any action taken by the agency, as appropriate.

 

(D)Any person who has knowledge of any instance of abuse or neglect, or alleged abuse/neglect, or suspected abuse/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 elderly person, shall immediately notify the appropriate law enforcement and county department of jobs and family services authorities in accordance

 

 

with section 5101.61 of the Revised Code.

(E) In addition to paragraph (D) of this rule, and consistent with provisions of division (A)(2) of section 340.03 of the Revised Code, notification of incidents indicating alleged abuse or neglect of any person served shall be forwarded to the community mental health board no later than twenty-four hours after discovery of the incident.

(F) Reportable incidents shall be documented on form "DMH-LIC-015" as required by the department, and shall be forwarded to both the department and the mental health board within twenty-four hours of their discovery, exclusive of weekends and holidays. Form "DMH-LIC-015" shall include identifying information about the agency, 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)]. A description of reportable incidents and reporting  instructions shall be included as part of form "DMH-LIC-015".

Effective:                                01/01/2004 R.C. 119.032 review dates:                           01/01/2009

CERTIFIED ELECTRONICALLY

Certification

10/23/2003

Date

Promulgated Under:   119.03

Statutory Authority:   5119.01(H), 5119.22,

5119.61(A), 5119.611(C)

Rule Amplifies:           5119.01(H), 5119.22,

5119.61(A), 5119.611(C)