Ohio Admin. Code 5122-26-13 - Incident notification and risk management
(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
elderly person
adult
age sixty and over , shall immediately notify the appropriate
law enforcement and county department of
jobs and family services authorities in accordance with section
5101.61
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.
Notes
Promulgated Under: 119.03
Statutory Authority: 5119.36
Rule Amplifies: 5119.36
Prior Effective Dates: 01/01/2004, 01/01/2012, 04/01/2016, 06/01/2017
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