Mich. Admin. Code R. 325.1924 - Reporting of incidents, quality review program
Rule 24.
(1) A
home for the aged must implement and maintain a quality review program
consistent with section
20175(8) of
the act , MCL
333.20175, and the professional
review function. The program is responsible for all of the following:
(a) Reviewing and evaluating
incidents.
(b) Identifying
effective means to correct any deficient practice.
(c) Ensuring resident safety and quality of
care.
(d) Improving
procedures.
(2) The
program must be reviewed annually by the administrator and governing
body .
(3) The program must be
staffed by a multi-disciplinary team. The multi-disciplinary team shall consist
of not less than 2 personnel that have training or experience with the type of
the incident being evaluated.
(4)
The multi-disciplinary team shall meet not less than twice each calendar year
or more frequently as needed to review an incident or incidents.
(5) Records must be maintained that
demonstrate incident reporting to the team, analyses, outcomes, corrective
action taken, and evaluation to ensure that the expected outcome is achieved.
These records must be maintained for 2 years.
(6) The facility must have a policy and
procedure to report an incident using a department approved form to the
multi-disciplinary team responsible for the quality review program required
under subrule (1) of this rule.
(7)
The facility must have a policy and procedure to ensure that an incident , once
known by facility staff , is reported as soon as possible, but not later than 48
hours after the incident , to a resident 's authorized representative or
designated health care professional, as appropriate. Verbal or written
notification must be documented in the resident 's record to reflect the date,
time, name of staff who made the notification, and name of the representative
or professional who was notified.
(8) If an elopement occurs, staff shall
conduct a search to locate the resident . If the resident is not located within
30 minutes after the elopement occurred, staff shall comply with subrule (7) of
this rule and contact the local police authority.
(9) The department may review a quality
review program during a renewal survey to confirm that a program is in place.
During a complaint investigation , the licensee shall confirm if an incident was
reviewed and if any corrective actions were taken, but the department shall not
request any other case'specific information that was part of the quality review
program . The department shall rely on other documents outside this professional
review function as part of its investigation. The department shall maintain and
protect these documents in accordance with state and federal laws, including
privacy laws.
Notes
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