N.Y. Comp. Codes R. & Regs. Tit. 18 § 487.15 - Investigations involving facilities subject to the Justice Center
Investigations involving facilities subject to the Justice Center shall proceed consistent with the following requirements:
(a) Facilities must investigate all
occurrences of reportable incidents, including injuries of unknown origin.
Facility policy and procedures must address the process of investigating an
incident at the facility level. Such process must include, at minimum, the
following elements:
(1) immediately upon
notice of an occurrence constituting a reportable incident, including injuries
of unknown origin, the facility must obtain a medical examination, as indicated
by the circumstances, of any physically injured individual, record the name of
the examiner and retain his/her written findings;
(2) the facility must promptly identify and
interview witnesses to the incident. Such interviews should be conducted by
qualified, objective individuals in a private area which does not allow those
not participating in the interview to overhear. Interviews must be conducted of
each party or witness individually, not in the presence of, or under
circumstances in which other parties or witnesses may perceive any aspect of
the interview. The person alleging the incident, or who is the subject of the
incident, must be offered the opportunity to give his/her version of the event.
At least one of the persons conducting the interview must have an understanding
of, and be able to accommodate, the unique needs or capabilities of the person
being interviewed;
(3) the facility
must review pertinent information (e.g., medical and other
records, observe the scene of the incident, expert assessments, outside service
provider information);
(4) the
facility must identify physical evidence, if any, and take appropriate measures
to safeguard and preserve such evidence;
(5) the facility must establish scope and
severity, including duration, staff involvement, number of residents involved
and resident outcomes;
(6) the
facility must document each of the investigative steps taken;
(7) upon completion of the investigation, a
written report shall be prepared by the facility which shall include all
relevant findings and information obtained in the investigation with reference
to the supporting information obtained in the investigation, and details of
steps taken to investigate the incident. The facility director must make a
written endorsement of such findings. Such findings must also identify and
document the remedial steps to be taken, and designate the person responsible
for assessing the efficacy of the remedial action taken. The results of the
investigation shall be promptly reported to the department and to the Justice
Center.
(b) The
investigation must be conducted by the administrator or case manager, or, if
applicable, the administrator's designee.
(c) Any information, including but not
limited to documents and other materials, obtained during or resulting from any
investigation shall be kept confidential, except as otherwise permissible by
law or regulation.
(d)
Investigations of reportable incidents must be completed, and the results of
such investigation reported to the department, within five calendar days of the
discovery of the incident. Additional time for completion of the investigation
may be allowed, subject to the approval of the department, upon a showing of
good cause for such extension. For purposes of this section,
complete shall mean that all necessary information has been
obtained to determine whether and how the incident occurred, to determine the
remedial action necessary to address the occurrence, and to complete the
findings referenced in paragraph (a)(7) of this section.
(e) If any remedial action is necessary, the
operator, in collaboration with the department, shall establish a plan in
writing. The plan shall indicate the operator's agreement to the remediation
and identify a follow-up date and person responsible for monitoring the
remedial action. The plan shall be provided, and any measures taken in response
to such plan shall be reported, to the Justice Center.
(f) Except to the extent otherwise prohibited
by law, the facility shall provide information, whether obtained pursuant to
the investigation or otherwise, to the Justice Center upon request, in the form
and manner requested. Such information must be provided in a timely manner so
as to support completion of the investigation subject to the time limits set
forth in subdivision (d) of this section. Failure to provide such information
in response to a reasonable request by the Justice Center shall be considered a
violation of the facility's responsibilities under these regulations. The
Department and the Justice Center shall, except as otherwise prohibited by law,
be permitted to share information obtained in their respective investigations
of incidents subject to the reporting requirements of this section.
(g) Incident review committees are
established; provided, however, that the department may consider and approve
requests for exemptions on a case-by-case basis, based on the size of the
facility or provider agency or other relevant factors. A request for an
exemption must include a written justification. Such committee shall consist of
persons identified by the director of the facility, including some members of
the following: at least two direct support staff, two licensed health care
practitioners, two residents and two family members, but not the director of
the facility or provider agency. Such committee shall meet to:
(1) review the timeliness, thoroughness and
appropriateness of the facility or provider agency's responses to reportable
incidents;
(2) recommend additional
opportunities for improvement to the director of the facility or provider
agency, if appropriate;
(3) review
incident trends and patterns concerning reportable incidents; and
(4) make recommendations for the director of
the facility or provider agency to assist in reducing reportable incidents.
Such meetings shall occur within one month following the issuance of findings
associated with the investigation of an incident, and in the absence of such
incident, no less than quarterly. Members of the committee shall be trained in
confidentiality laws and regulations, and shall comply with section
74 of the
Public Officers Law.
(h)
The department and the Justice Center may undertake investigations even if the
facility is also investigating a matter. Investigations undertaken by the
department shall conform to the elements specified in subdivision (a) of this
section. Department investigations shall also comply with subdivisions (c), (d)
and (e) of this section, except that the deadline for providing the final
report of the investigation to the Justice Center shall be 50 days from the
date the Justice Center accepted a report of abuse or neglect, and 60 days from
the date the Justice Center accepted a report of a significant
incident.
(i) The department or the
Justice Center may direct a facility to cease its investigation, or to modify
its investigation, even if such direction results in practice which varies from
the requirements of subdivisions (a) through (g) of this section. The facility
shall maintain documentation of such directives within the facility's records.
Such documentation shall include the name of the department or Justice Center
representative issuing the directive and the date when the facility was
directed to cease its investigation.
Notes
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