(A) This rule establishes standards to ensure
the prompt and accurate notification of certain prescribed incidents.
(B) Definitions.
(1) "County
community mental health board
Board of
residence" means the mental health board
that is responsible for referring and/or
paying for the resident's treatment.
(2) "Incident" means an event that poses a
danger to the health and safety of residents and/or staff and visitors of the
facility, and is not consistent with routine care of persons served or routine
operation of the facility.
(3)
"Reportable Incident" means an incident that must be submitted to the
department in accordance with this rule, including an incident that must then be forwarded by the
department to the Ohio legal rights service pursuant to section 5123.604 of the
Revised Code. As referenced in division (C)
(E) of section
5119.611
5119.36
of the Revised
Code, "Major Unusual Incident" has the same meaning as "Reportable
Incident."
(4) "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.
(5) "Six
month incident data report" means a data report which must be submitted to the
department.
(C) The
operator 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 residents, staff, and visitors. The operator shall identify in policy other
incidents to be reviewed.
(1)
For a type 1 residential facility, an
An incident report shall be submitted in written
form to the operator or designee within twenty-four hours of discovery of the
incident.
As part of the facility's
performance improvement process, a
A
periodic review and analysis of reportable incidents, and other incidents as
defined in facility policy, shall be performed. This
shall include any action taken by the operator, as appropriate, including
actions recommended by the provider from which the resident receives services.
This should be incorporated as part of the facility's performance improvement
process, as applicable.
(2) For a type 2 and type 3
residential facility, an incident report shall be submitted in written form to
the operator within twenty-four hours of discovery of the
incident.
A periodic review and analysis of
reportable incidents, and other incidents as defined in facility policy, shall
be performed. This shall include any action taken by the operator, as
appropriate, including actions recommended by the agency from which the
resident receives services.
(3)
(2) The operator 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
, or of an alleged crime which would
constitute a felony, of
:
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
(1) Any child or adolescent, shall
immediately notify any alleged or suspected abuse or neglect to 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 of an alleged crime against a child or adolescent which would
constitute a felony, including a crime allegedly committed by another child or
adolescent which would constitute a felony if committed by an adult, shall
immediately notify law enforcement authorities.
(2)
(E)
Any person who has knowledge of any instance of abuse,
neglect, or exploitation; alleged or suspected abuse, neglect, or exploitation;
or of an alleged crime againstAn
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.
(F)
Any person who has knowledge of an alleged crime against a
child or adolescent, including a crime allegedly committed by another child or
adolescent, shall immediately notify law enforcement
authorities.
(E)
(G) Each operator shall submit reportable incidents
and six month reportable incidents to the department.
(1) Each operator of a
type
class 1
facility shall submit reportable incidents and six month reportable incidents
as defined by and according to the schedule included in appendix A to this
rule.
(2) Each operator of a
type
class 2
and type
class 3 facility shall submit reportable incidents as
defined by appendix C to this rule.
(F)
(H)
Each reportable incident shall be documented and
reported on form "DMH-LIC-015" as required by the department. Form
"DMH-LIC-015" shall include identifying information about the operator, date,
time and type of incident, and resident information that has been de-identified
pursuant to the HIPAA privacy regulations, [ 45 C.F.R. 164.514(b)(2)
].
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 operator 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 residents, staff, and
visitors; and
.
(2) The
operator shall forward each reportable incident to the department and to each
of the following within twenty-four hours of its discovery, exclusive of
weekends and holidays:
(a)
County community mental health board
The board of residence and the board whose service district includes the facility,
for individuals with mental illness; and,
;
(b)
The
mental health agency
provider from which the mental health resident is
receiving services
, if applicable; and
.
(c) For type 2 and type 2
residential facilities, to the mental health agency with which the facility is
affiliated, if different from the agency specified in paragraph (C)(1)(a) of
this rule.
(3) The operator shall notify the resident's
parent, guardian or custodian, if applicable, within twenty-four hours of
discovery of a reportable incident, and document such notification.
(a) Notification may be made by phone,
mailing, faxing or e-mailing a copy of the incident form, or other means
according to facility policy and procedures.
(b) When notification does not include
sending a copy of the incident form, the facility must inform the parent,
guardian or custodian, of his/her right to receive a copy, and forward a copy
within twenty-four hours of receiving a request for a copy. The facility shall
document compliance with the provisions of this paragraph.
(G)
(I) Each operator of a
type
class 1 facility
shall submit a six month incident data report to the department. utilizing the
form that is in appendix B of this rule.
Each operator must submit the six month incident data report
according to the following schedule:
(1) The six month incident data report for
the period of January first to June thirtieth of each year shall be submitted
no later than July thirty-first of the same year.
(2) The six month incident data report for
the period of July first to December thirty-first of each year shall be
submitted no later than January thirty-first of the following year.
(H)
(J) 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 residential facility,
a
regulatory or enforcement authority,
or the
community mental health board
and/or the affiliating mental health
agency.
In the case of class one facilities, a
board shall have the authority to inspect any facility which has residents for
which the board is providing funding for community mental health
services.
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