PART 624

REPORTABLE INCIDENTS, SERIOUS REPORTABLE INCIDENTS, AND ABUSE
                   IN FACILITIES OPERATED OR CERTIFIED BY OMRDD

 (Statutory authority: Mental Hygiene Law, 13.07, 13.09, 16.00)

Effective Date(s); 06/14/95 r/a PT624

 
     Sec.
     624.1  Applicability
     624.2  Background and intent
     624.3  Statutory authority
     624.4  Reportable incidents, serious  reportable  incidents  and  abuse,
              defined
     624.5  Reporting, recording and investigation
     624.6  Notifications
     624.7  Standing committee to review and  monitor  reportable  incidents,
              serious  reportable  incidents,  and  allegations  of  abuse to
              persons receiving services from the agency
     624.8-624.19 (Reserved)
     624.20 Glossary

| Posted: 8-16-06


 
       Section  624.1  Applicability.
Effective Date(s); 06/14/95 r/a 624.1; 01/25/06 amd 624.1
        (a)  This  Part  as  it relates to services for persons (see glossary)
      with developmental disabilities (see glossary) and  applies  to  persons
      receiving  services in any facility (see glossary) operated or certified
      by the Office of  Mental  Retardation  and  Developmental  Disabilities,
      hereinafter referred to as OMRDD.
        (b)  In  addition,  this Part is controlling over any other Part of 14
      NYCRR insofar as the reporting, investigation (see glossary), review  or
      monitoring  of incidents, allegations (see glossary) of abuse to persons
      receiving services, or  other  potentially  harmful  events  related  to
      persons  receiving  services, may be concerned, unless said Part is more
      restrictive and specifically states that it is controlling.
        (c) This Part  applies  to  any  developmental  disabilities  services
      office  (see  glossary),  hereinafter referred to as a DDSO, operating a
      developmental center or certified facility; or any  voluntary  (not-for-
      profit)  agency  operating a certified facility. When the term, "agency"
      is used herein, this shall mean the requirement(s) is applicable to both
      DDSOs and voluntary agencies.
        (d) Pursuant to section 635-10.1(c) of this Title, Home and  Community
      Based  Waiver  Services  (HCBS) providers shall comply with the require-
      ments of this Part.
 
       624.2  Background and intent. 
Effective Date(s); 06/14/95 r/a 624.2
(a) The purposes for reporting, investi-
     gating, reviewing, correcting and/or monitoring certain events or  situ-
     ations  are  to  enhance  the  quality  of care provided to persons with
     developmental disabilities who are in facilities, to  protect  them  (to
     the extent possible) from harm, and to ensure that such persons are free
     from mental and physical abuse.
       (b)  The  primary function of the reporting of certain events or situ-
     ations is to enable a governing body (see glossary), executives,  admin-
     istrators  and  supervisors to become aware of problems, to take correc-
     tive measures, and to minimize the potential for recurrence of the  same
     or  similar  events or situations. The prompt reporting of alleged abuse
     can ensure that immediate steps are taken to protect persons from  being
     exposed to the same or similar risk.
       (c)  The  reporting  of certain events or situations in an orderly and
     uniform manner facilitates identification of trends,  whether  within  a
     facility or class of facilities, by one or more agencies, or on a state-
     wide  basis, which ultimately allows for the development and implementa-
     tion of preventive strategies.
       (d) It is the intent of this Part to require a process  whereby  those
     significant  events  or  situations which endanger a person's well-being
     while in or under the auspices  of  a  certified  facility,  defined  in
     section 624.4 of this Part as "reportable incidents" or "serious report-
     able  incidents,"  are  reported, investigated, reviewed, and corrective
     actions are taken as necessary.
       (e) It is the intent of this Part to  require  a  process  whereby  an
     allegation  (see  Glossary) of the abuse, as defined in section 624.4 of
     this Part, while a person is in or under the  auspices  of  a  certified
     site,  is  reported, investigated, reviewed and corrective actions taken
     as necessary.
       (f) It is not the intent of this Part to mandate that every potential-
     ly harmful event, occurrence, or situation attributable to or  involving
     a  person  receiving services in certified facilities such as an aggres-
     sive behavior problem (including the need for psychiatric services else-
     where), illness, medication problem, inappropriate  living  arrangements
     or  conditions,  or  inappropriate  social  behavior,  be  recorded as a
     reportable incident or serious reportable  incident.  It  shall  be  the
     responsibility  of  the  agency  (see  glossary) to determine if and how
     events or situations involving persons receiving  services,  other  than
     reportable  incidents,  serious reportable incidents, and allegations of
     abuse (as defined in section 624.4 of this Part), are to be  documented,
     processed,  corrected  (including corrective actions to be taken for the
     protection and/or safety of all those exposed to potential harm),  moni-
     tored  and  analyzed  for trends through the development of policies and
     procedures that are in compliance with 14 NYCRR; and to develop a  mech-
     anism for review to ensure compliance with such policies and procedures.
       (g)  It  is  the  intent of this Part to require a process whereby all
     serious behavior problems are recorded, reviewed by appropriate parties,
     and a record maintained of actions taken. However, reporting through the
     incident/abuse process  shall  only  occur  when  the  behavior  problem
     results  in  an  incident  or  an allegation of abuse as defined in this
     Part.
       (h) It is the intent of this Part to require  a  process  whereby  the
     governing  body ensures the effectiveness of the identification, record-
     ing, investigation, review and corrective actions with regard to  events
     or  situations  involving  persons  receiving services referenced within
     this Part. This shall be  achieved  through  the  establishment  of  the
     governing body's own protocol, which may include but shall not be limit-
     ed  to:  regular  review  of the minutes of the standing committee which
     reviews and monitors reportable incidents, serious reportable incidents,
     and allegations of abuse, and periodic attendance  at  that  committee's
     meetings.
       (i)  It  is the intent of this Part to hold the governing body and the
     chief executive officer (see glossary) responsible for the management of
     incidents and alleged abuses. However, the chief executive  officer  may
     designate  a  senior  staff  member (see glossary) or members (such as a
     program administrator - see glossary) to assume  specified  responsibil-
     ities to facilitate the day to day process, and these designations shall
     be set forth in writing in agency policy/procedure and make known to all
     staff and others with a need to know.
       (j)  Though  failure  on  the part of an agency or facility to provide
     humane care and treatment may not meet the definition  of  a  reportable
     incident, serious reportable incident, or abuse in conformance with this
     Part,  OMRDD  has,  pursuant to statute, the authority to investigate or
     cause the investigation  of  the  conduct,  performance  and/or  alleged
     neglect  of  duty.  Whether  such  situations  reflect the philosophical
     ideology or orientation of an agency or reflect a lack of sensitivity to
     the issues at hand does not minimize the responsibility and  prerogative
     of  OMRDD to investigate and/or promote recommendations for changes when
     seen as being in the best interest of persons receiving services.
 
       624.3 Statutory authority. 
Effective Date(s); 06/14/95 r/a 624.3; 02/08/06 amd 624.3(l)
(a) Section 13.01 of the Mental Hygiene Law
      establishes  that  New  York State has responsibility for the comprehen-
      sively planned care, treatment, and rehabilitation of New  York  State's
      citizens with developmental disabilities.
        (b)  Section 13.07(c) of the Mental Hygiene Law establishes that OMRDD
      shall have responsibility for seeing  that  persons  with  developmental
      disabilities  who  are  receiving care and treatment have their personal
      and civil rights protected.
        (c) Section 13.09(b) of the Mental Hygiene Law grants the commissioner
      of OMRDD the authority to adopt  rules  and  regulations  necessary  and
      proper to implement any matter under his or her jurisdiction.
        (d)  Section 13.21(b) of the Mental Hygiene Law requires the reporting
      of every complaint of abuse or mistreatment in  a  developmental  center
      (see  Glossary) to its board of visitors and to the Mental Hygiene Legal
      Service (see glossary); and notifying the  district  attorney  or  other
      appropriate  law  enforcement  officials  if it appears that a crime may
      have been committed.
        (e) Section 13.33 of the Mental Hygiene  Law  empowers  the  board  of
      visitors  of  State  operated  facilities  to  investigate  all cases of
      alleged abuse or mistreatment charged against an employee and to  inter-
      view  persons  receiving services, employees of the facility, and family
      care providers in pursuit of  such  investigations  where  such  alleged
      abuse or mistreatment took place.
        (f)  Section  16.01 of the Mental Hygiene Law enables the commissioner
      to regulate and assure the consistent high quality of services  provided
      within the state to persons with developmental disabilities.
        (g)  Section  16.13  of  the  Mental Hygiene Law requires providers of
      services to notify  the  district  attorney  or  other  appropriate  law
      enforcement  officials  and the commissioner as soon as possible, but at
      least within three working days, if it appears that  a  crime  may  have
      been  committed  against  a  person receiving services. It also requires
      that if there is reason to believe that the crime may have occurred in a
      facility or program of any other service provider  licensed,  certified,
      funded,  or  operated by a State agency (see Glossary), the chief execu-
      tive officer of such other provider of services  shall  be  notified  as
      soon as possible, but within three working days, though this requirement
      is  waived  if the provider of services is alleged to have committed the
      crime.
        (h) Sections 16.11 and 16.13 of the Mental Hygiene Law  authorize  the
      commissioner  or  an authorized representative to conduct investigations
      and inspections and permit review of a facility and all  its  books  and
      records.
        (i)  Section 16.13 of the Mental Hygiene Law requires holders of oper-
      ating certificates  issued  by  the  commissioner  to  cooperate  during
      inspections  by  permitting  review  of a facility and all its books and
      records.
        (j) Section 16.17 of the Mental Hygiene Law authorizes the commission-
      er to revoke, suspend, or limit an operating certificate for failure  to
      comply with the provisions of applicable statutes, rules or regulations;
      and  permits  the  removal  of  any or all persons receiving services if
      there is a situation that poses imminent danger to the health or  safety
      of any person.
        (k) Section 16.19 of the Mental Hygiene Law addresses the confinement,
      care  and  treatment of persons who have a developmental disability; and
      empowers the commissioner to cause an investigation to be made into  any
      situation  when there is reason to believe that a person with a develop-
      mental disability is being  detained  or  given  inadequate,  cruel,  or
      unsafe care by anyone.
        (l)  Section  29.29 of the Mental Hygiene Law requires the compilation
      and analysis of incident reports in State operated  facilities  and  the
      submission  of aggregated information to the State Commission on Quality
      of Care and Advocacy for Persons with Disabilities on at least a semian-
      nual  basis; composition of a committee to review incidents within State
      operated facilities is also specified.
        (m) Article 33 of the Mental Hygiene Law establishes the  basic  civil
      rights pertaining to persons receiving services for mental disabilities.
      Section  33.13  establishes standards for clinical records and confiden-
      tiality.
        (n) Section 33.03 of the Mental  Hygiene  Law  establishes  that  each
      person receiving services shall receive care and treatment that is suit-
      ed to his or her needs and skillfully, safely, and humanely administered
      with full respect for his or her dignity and personal integrity.
        (o) Section 41.41 of the Mental Hygiene Law ensures each person resid-
      ing  in  a community residence has the right to be free from physical or
      psychological restraint or pressure.
        (p) Section 45.19 of  the  Mental  Hygiene  Law  requires  the  prompt
      reporting  of  any  allegations  of  abuse  or  mistreatment of a person
      receiving services to the State Commission on Quality of  Care  for  the
      Mentally Disabled.
        (q)  Article 47 of the Mental Hygiene Law describes the Mental Hygiene
      Legal Service and its functions, powers and duties.
        (r) Article 6,  Title  6  of  Social  Service  Law,  Child  Protective
      Services,  requires  the reporting of suspected child abuse or maltreat-
      ment to a statewide register.
 
        624.4  Reportable  incidents,  serious  reportable  incidents,  abuse,
     defined.
Effective Date(s); 06/14/95 r/a 624.4
      (a) In relation to a facility (see Glossary), reportable  inci-
     dents, serious reportable incidents and abuse are those events which, in
     accordance  with  the  requirements  of  section 624.5 of this Part, are
     required to be recorded, reviewed, investigated and reported  to  desig-
     nated  parties  according  to  established  procedures  of  the  agency;
     reviewed by a standing committee;  and  acted  upon  in  an  appropriate
     manner  to safeguard the well-being of persons receiving services and to
     bring the matter to closure.
       (b) Reportable incidents and serious reportable  incidents.    Signif-
     icant  events or situations endangering a person's well-being. A serious
     reportable incident is a  reportable  incident  which,  because  of  the
     severity  or  sensitivity  of  the  situation,  must also be immediately
     reported to DDSO in whose area of jurisdiction the incident occurred and
     followed up in writing on Form OMR 147(I), Reportable Incident Reporting
     Form, to that DDSO.
 
     Reportable Incidents                  Serious Reportable Incidents
 
     (1) Injury. Any suspected or          Any injury which results in the
         confirmed harm, hurt, or damage   admission of a person to a hos-
         to a person receiving services,   pital or 24-hour infirmary for
         caused by an act or that person   treatment or observation because
         or another, whether or not by     of the injury. (Note: If the in-
         accident, and whether or nor the  jury suspected to have been caused
         cause can be identified, which    by abuse, the abuse is to be
         results in a person requiring     reported; see subdivision (c)
         medical or dental treatment       of this section.)
         (see Glossary) by a physician,
         dentist, physician's assistant,
         or nurse practitioner, and such
         treatment is more than first aid.
         Illness, in and of itself, shall
         not be reported as an injury
         or any other type of incident.
 
     (2)                                   Missing Person. The unexpected  or
                                           unauthorized  absence  of a person
                                           after  formal  search   procedures
                                           (see Glossary) have been initiated
                                           by the agency:
                                             (i)   Formal  search  procedures
                                             must be initiated if a  person's
                                             where-abouts   are  unknown  for
                                             four hours. An  incident  report
                                             is   to  be  initiated  at  this
                                             point.
                                             (ii) Reasoned  judgment,  taking
                                             into  consideration the person's
                                             habits, deficits,  capabilities,
                                             health   problems,  etc.,  shall
                                             determine   when   such   formal
                                             search  procedures  need  to  be
                                             implemented.
                                             (iii) It is mandated that formal
                                             search procedures  be  initiated
                                             immediately  upon  discovery  of
                                             the absence of  a  person  whose

 

                                             absence constitutes a recognized
                                             danger to the possible wellbeing
                                             of that person or others.
 
     (3) Death. All loss of life,          Death when due to circumstances
         regardless of cause.              unrelated to the natural cause of
                                           illness   or   disease  or  proper
                                           treatment   in   accordance   with
                                           accepted   medical  standards;  an
                                           apparent homicide or  suicide;  or
                                           an   unexplained   or   accidental
                                           death.
 
     (4)                                   Restraint. The act of limiting  or
                                           controlling  a  person's  behavior
                                           through the use of:
                                             (i)   Any device which  prevents
                                             the  free  movement of both arms
                                             or both legs, as  ordered  by  a
                                             physician.
                                             (ii)  Any  device  which totally
                                             immobilizes  (see  Glossary)   a
                                             person,  as  ordered by a physi-
                                             cian.
                                             (iii) Any   device   which    is
                                             ordered  for the express purpose
                                             of controlling  behavior  in  an
                                             emergency (see Glossary
                                             NOTE: Nothing in this Part shall
                                             prevent  the  use  of mechanical
                                             supports  to  provide  stability
                                             necessary  for therapeutic meas-
                                             ures such as  immobilization  of
                                             fractures,   administration   of
                                             intravenous or  other  medically
                                             necessary procedures.
                                             (iv)  Any  medication as ordered
                                             by a physician which  renders  a
                                             person  unable to satisfactorily
                                             participate   in    programming,
                                             leisure or other activities.
 
     (5) Medication Error. That situation  Only when the error results in
         in which a person evidences       the admission of a person to a
         marked adverse effects or a       hospital or 24-hour infirmary for
         person's health or welfare is     treatment or observation.
         in jeopardy due to:
         (i)   The    administration   of
         medication   in   an   incorrect
         dosage,  in  an incorrect speci-
         fied form, by incorrect route of
         administration, or which has not
         been prescribed or ordered.
         (ii)  Administration of a  medi-
         cation to the wrong person.
         (iii) Failure  to  administer  a
         prescribed medication.

 

         NOTE: Errors which do not result
         in marked  adverse  effects  are
         not  reportable  incidents,  but
         must be documented in a person's
         record in accordance with agency
         procedures  and  shall  be dealt
         with administratively.
 
     (6)                                   Possible Criminal Acts. Actions by
                                           persons receiving  services  which
                                           are  or  appear to be a crime (see
                                           Glossary) under New York State  of
                                           Federal Law.
 
     (7) Sensitive Situations. Those       Those sensitive situations which,
         situations involving a person     in the judgment of the chief exe-
         receiving services which are not  cutive officer, need to be brought
         described above, which may be of  to the attention of OMRDD, through
         a delicate nature to the agency,  the DDSO, as expeditiously as
         and which are reported to the     possible.
         administration to ensure
         awareness of the circumstances.
 
       (c)  Abuse.  The  maltreatment  or  mishandling  of a person receiving
     services which would endanger the physical or  emotional  well-being  of
     the person through the action or inaction on the part of anyone, includ-
     ing  an employee, intern, volunteer, consultant, contractor, visitor, or
     others, whether or not the person is or appears to be injured or harmed.
     The failure to exercise one's duty to intercede in behalf  of  a  person
     receiving  services  also  constitutes  abuse.  While a person receiving
     services may have allegedly abused another person receiving services, it
     is necessary to take into consideration the  aggressor's  judgement  and
     cognitive capabilities to determine whether the act is to be reviewed as
     an  abuse  allegation  or  as a behavioral problem. All allegations (see
     Glossary) of abuse are to be reported on a standardized form (see  Glos-
     sary); reviewed, investigated and reported to designated parties accord-
     ing  to  established  procedures;  reviewed by a standing committee; and
     acted upon in an appropriate manner by the chief  executive  officer  to
     safeguard  the well-being of persons receiving services and to bring the
     matter to closure. All such allegations of   abuse must  be  immediately
     reported  to  DDSO  in  whose  area  the  alleged abuse occurred and and
     followed up in writing on Form OMR 147(A), Allegation of   Abuse.  Abuse
     is categorized as follows:
       (1)  Physical  abuse.  Physical  contact which may include, but is not
     limited to, such obvious physical actions as hitting,  slapping,  pinch-
     ing,  kicking, hurling, strangling, shoving, unauthorized or unnecessary
     use of personal intervention, or otherwise mishandling a person  receiv-
     ing  services. Physical contact which is not necessary for the safety of
     the person and/or causes discomfort to the person may also be considered
     to be physical abuse, as may the handling of a person  with  more  force
     than is reasonably necessary.
       (2)  Sexual  abuse.  Any  sexual  contact  between  a person receiving
     services and an employee, intern, consultant, contractor or volunteer of
     an agency is always considered to be sexual abuse and is prohibited. Any
     sexual contact between persons receiving services and others,  or  among
     persons  receiving services, is considered to be sexual abuse unless the
     involved person(s) is a consenting adult. This shall not  include  those
     situations  in  which a person with a developmental disability who was a
     service recipient becomes an employee of a service provider organization
     and already has a relationship with another  service  recipient  of  the
     same or another service provider organization; in such a situation, this
     shall  be  noted in the person's service plan and the relationship shall
     not be considered as "sexual abuse" unless there  is  reson  to  believe
     that  there is harassment coercion, exploitation, etc.  involved. Sexual
     contact is defined as the touching or fondling of the  sexual  or  other
     intimate parts of a person, not married to the actor, for the purpose of
     gratifying  the  sexual  desire  of  either  party,  whether directly or
     through clothing. Sexual contact also includes causing a person to touch
     anyone else for the purpose of arousing or  gratifying  personal  sexual
     desires.
       (3)  Psychological  abuse. The use of verbal or non-verbal expression,
     or other actions, in the presence  of  one  or  more  persons  receiving
     services  that  subjects  the person(s) to ridicule, humiliation, scorn,
     contempt or dehumanization, or  is  otherwise  denigrating  or  socially
     stigmatizing.  In  addition  to  language  and/or  gestures, the tone of
     voice, such as that used in screaming or shouting at or in the  presence
     of persons receiving services, may, in certain circumstances, constitute
     psychological abuse.
       (4)  Seclusion.  The  placement  of a person in a secured room or area
     from which he or she cannot leave at will. This does not include  place-
     ment  in a time-out (see Glossary) room as part of a behavior management
     plan that meets all applicable requirements. Seclusion is considered  to
     be a form of abuse and is, therefore, prohibited.
       (5)  Unauthorized  or  inappropriate  use  of  restraint. The use of a
     mechanical restraining device to control a person without  the  written,
     prior  authorization  of  a  physician or the "senior staff member" (see
     Glossary) if the physician cannot be present within 30 minutes;  or  the
     use  of  a mechanical restraining device without it being specified in a
     plan of services; or used for medical purposes (see Glossary) without  a
     physician's  order.  The  intentional  use  of a medication to control a
     person's behavior that has not been prescribed by a physician  for  that
     purpose  is considered to be unauthorized use of restraint.  Inappropri-
     ate use of a restraint shall include, but not be limited to, the use  of
     a  device(s)  or  medication  for  the  convenience, as a substitute for
     programming, or for disciplinary (punishment) purposes.
       (6) The unauthorized or inappropriate  use  of  aversive  conditioning
     (see  "Conditioning,  Aversive" in Glossary). The use of aversive condi-
     tioning without appropriate permissions is the unauthorized use of aver-
     sive conditioning. Inappropriate  use  of  aversive  conditioning  shall
     include,  but  not  be  limited to, the use of the technique for conven-
     ience,  as a substitute for programming, or  for  disciplinary  (punish-
     ment) purposes.
       (7)  The unauthorized or inappropriate use of time-out (see "Time-out"
     in Glossary). The use of time-out without appropriate permissions is the
     unauthorized use  of  time-out.  Inappropriate  use  of  time-out  shall
     include, but not be limited to, the use of the technique for the conven-
     ience, as a substitute for programming, or for disciplinary (punishment)
     purposes.
       (8) Violation of a person's civil rights. Any action or inaction which
     deprives a person of the ability to exercise his or her legal rights, as
     articulated in State or Federal Law.
       (9) Mistreatment. The deliberate and willful determination on the part
     of  an  agency's  administration  or staff to follow treatment practices
     which are contraindicated by a person's plan of services (see Glossary),
     which violate a person's human rights, or do not follow accepted  treat-
     ment practices and standards in the field of developmental disabilities.
       (10)  Neglect.  A  condition of deprivation in which persons receiving
     services receive insufficient, inconsistent or  inappropriate  services,
     treatment,  or care to meet their needs; or failure to provide an appro-
     priate and/or safe environment for persons receiving services.   Failure
     to  provide  appropriate  services,  treatment or care by gross error in
     judgment, inattention or ignoring may  also  be  considered  a  form  of
     neglect.
        624.5  Reporting, recording and investigation. 
Effective Date(s); 06/14/95 r/a 624.5; 02/08/06 amd 624.5(b)(4)
(a) Policies and procedures.
        (1) Every DDSO and voluntary agency (or agency as both are referred to
      herein) with oversight responsibilities for one or more facilities shall
      develop incident/abuse policies and procedures that are  in  conformance
      with this Part to ensure:
        (i) Reporting, recording, investigation, review and monitoring; and
        (ii)   Identification  of  reporting  responsibilities  of  employees,
      interns, volunteers, consultants, contractors, and family  care  provid-
      ers.
        (2) Agency policies and procedures, whether newly developed or repres-
      enting  change  from  previously  approved policies, shall be subject to
      approval by the agency's governing body and shall be in compliance  with
      this Title.
        (3)  Policies/procedures  shall be made known to all persons receiving
      services and their parent, guardian, or correspondent (see Glossary)  or
      advocate  (see  Glossary);  to  agency  employees,  interns, volunteers,
      consultants, and contractors; and to family care providers (see  Glossa-
      ry).   This  may  be  done  by  providing  a  copy  of  the  appropriate
      policies/procedures to those with a need to know (e.g., staff,  consult-
      ants, family care providers) or as an overview to others.
        (4)  Agency  policy  shall require that internal reports are made on a
      standardized form(s) (which may have been designed for that  purpose  or
      may be multi-purpose), as selected by the agency.
        (b) General reporting requirements.
        (1)  The chief executive officer (or designee) shall be advised of all
      reportable incidents within 48 hours of their occurrence  or  discovery.
      However,  any  serious  reportable  incident  or any allegation of abuse
      shall be reported immediately (but no later than 24 hours) upon observa-
      tion or discovery to the chief executive officer (or designee).
        (2) Any report of a serious reportable incident or allegation of abuse
      shall immediately  be  investigated  in  accordance  with  the  agency's
      policies/procedures.  Said  investigation  shall  result  in  a  written
      preliminary finding within 24 hours of the initial report of  a  serious
      reportable  incident or allegation of abuse. The chief executive officer
      is responsible for ensuring that such action is taken as is necessary to
      protect the safety and welfare  of  the  person(s)  receiving  services.
      Subsequent thereto, the agency shall observe its own policies and proce-
      dures  for  the  reporting and investigation of alleged abuse as well as
      the requirements set forth in this Part.
        (3) Any serious reportable incident or any allegation of  abuse  shall
      be  reported  immediately  to the DDSO by telephone or other appropriate
      methods; and,
        (i) A written report of any serious reportable incident shall be  sent
      to  the  DDSO  on  Form  OMR 147(I), Reportable Incident Reporting Form,
      Reportable Incident Reporting Form within 24  hours  of  observation  or
      discovery,  and  shall  contain such information as is known at the time
      the form is completed.
        (ii) A written report of any allegation of client abuse shall be  sent
      to  the  DDSO on Form OMR 147(A), Report of Alleged Client Abuse, within
      24 hours of occurrence or discovery, and shall contain such  information
      as is known at the time the form is completed.
        (4) A written report, documented on Form OMR 147(A), of any allegation
      of abuse is to be sent to the Commission on Quality of Care and Advocacy
      for  Persons with Disabilities (see Glossary) within 48 hours of discov-
      ery.
        (5) An allegation of abuse, involving a person who resides in a facil-
      ity requires a written report on Form OMR  147(A)  to  be  sent  to  the
      Mental  Hygiene  Legal Service (see Glossary) within three working days.
      If a person resides in a State operated facility, notification  on  Form
      OMR  147(A) shall also be made within three working days to the board of
      visitors  of  the  applicable DDSO. The Mental Hygiene Legal Service and
      the board of visitors shall be informed of the results of  the  investi-
      gation.
        (6)  Any  reportable  incident,  serious  reportable  incident, or any
      instance of alleged abuse is to be thoroughly investigated by the  chief
      executive  officer  or  designated senior staff. A full investigation of
      serious reportable incidents or allegations of abuse  shall  take  place
      immediately or subsequent to preliminary findings, with further investi-
      gation undertaken commensurate with the seriousness and circumstances of
      the situation. All such investigations shall be documented.
        (c) Investigation, follow-up and records maintenance.
        (1)  No  one  may  participate  in the investigation of any reportable
      incident, serious reportable incident, or allegation of abuse  in  which
      he or she was directly involved, in which his or her testimony is incor-
      porated,  or  in  which a spouse or immediate family member was directly
      involved. When a serious reportable incident or allegation of  abuse  is
      to  be  investigated, every effort is to be made to have someone conduct
      or review the investigation who is not an immediate supervisor of  staff
      directly  involved  with the situation or event so as to be as disinter-
      ested and objective a party as possible. Those  who  are  members  of  a
      standing  committee  to review and monitor reportable incidents, serious
      reportable incidents, and allegations of abuse shall  not  routinely  be
      assigned the responsibility of investigating such events.
        (2)  Unless  deemed necessary by OMRDD or a DDSO, multiple independent
      investigations of a single situation are not required.
        (3) With regard to all reportable incidents, serious reportable  inci-
      dents, and/or all allegations of abuse, a person's safety must always be
      the primary concern of the chief executive officer. He or she shall take
      whatever  measures  appear  to  be  reasonable and prudent to ensure the
      protection of a person from further  harm,  injury,  or  abuse,  and  to
      provide prompt treatment or care. When appropriate, an employee, intern,
      volunteer,  consultant,  or  contractor  alleged to have abused a person
      shall be removed from immediate proximity to, or responsibility for, the
      person.
        (4) Appropriate action is to be taken when  there  is  an  injury  (as
      defined  in  section  624.4(b)(2)  of  this Part), which, upon review or
      investigation is determined to be of unknown origin. On no less than  an
      annual  basis such injuries are to be reviewed; overall corrective meas-
      ures taken, as may be applicable; and trends are to be analyzed.
        (5) OMRDD has, pursuant to statute, the right to review and/or  inves-
      tigate  any  reportable  incident,  serious  reportable incident, and/or
      allegation of abuse regardless of the source  of  the  information.  All
      relevant  records, reports and/or minutes of meetings at which the inci-
      dent or alleged abuse was discussed shall be made available to reviewers
      or investigators. Persons receiving services, staff and any other  rele-
      vant  parties may be interviewed in pursuit of any such review or inves-
      tigation. Such reviews and/or investigations include those conducted  by
      a DDSO. OMRDD shall ensure confidentiality.
        (6)  Reportable  incident,  serious  reportable  incident,  and  abuse
      records and subsequent reports or documentation of investigations  shall
      be  maintained  so  as  to  protect  the  privacy  of  persons receiving
      services, anyone else involved, or others whose names may appear in  the
      report.   Such records shall be retrievable by the person's name and, if
      used, filing number of identification code.
        (d) Irregular situations.
        (1) A reportable incident, serious  reportable  incident,  or  alleged
      abuse  occurs while a person is still directly under the auspices of the
      agency, but is not physically at the facility (e.g., in a restaurant, at
      the doctor, visiting family, in school, on a  vacation  trip,  at  camp,
      receiving non-certified services at a non-certified location).
        (i)  The process to be followed shall be the same as would be followed
      had the situation happened in the facility.
        (ii) Investigation and follow-up shall be made to the extent possible,
      and  available  community  resources  utilized  (e.g.,  law  enforcement
      authorities,  department  of  social services child and adult protective
      services).
        (2) A reportable incident, serious reportable incident,  or  abuse  is
      alleged  by  a  facility  to  have occurred while a person was under the
      supervision of another agency's facility (e.g., day  treatment  facility
      staff allege that a situation occurred at a residence, residential staff
      allege that a situation occurred at a workshop).
        (i) The discovering agency shall make a written record of the report.
        (ii)  The  discovering agency shall determine if the event has or will
      be duly reported and investigated by the other agency/facility.
        (iii) The agency in whose facility  or  under  whose  auspices  (e.g.,
      transportation)  the  serious reportable incident or abuse is alleged to
      have occurred shall report the situation to its DDSO.
        (iv) It shall be the responsibility of the agency with authority  over
      the  facility or service where the situation is alleged to have occurred
      to investigate, review, correct and monitor the situation; to  keep  the
      discovering agency informed of the progress and outcome, and to keep its
      DDSO informed as required by subdivision (e) of this section.
        (v)  If the agency suspecting or alleging the incident or abuse is not
      satisfied that the situation will be or is being investigated or handled
      appropriately, it shall bring the situation  to  the  attention  of  its
      DDSO.  The DDSO shall follow-up and take whatever steps may be necessary
      to ensure appropriate action by the other agency or by another DDSO  (as
      applicable).
        (3)  A  reportable  incident, serious reportable incident, or abuse is
      alleged to have occurred while a person, who  attends  a  certified  day
      program, was at another, location (e.g., at home, at a friend's home).
        (i) An incident report shall be completed.
        (ii) The information shall be evaluated and a determination made as to
      the  appropriate  course of action to be taken immediately and/or subse-
      quently.
        (iii) Investigation and follow-up shall be made to the  extent  possi-
      ble,  and  available community resources utilized (e.g., law enforcement
      authorities, department of social services child  and  adult  protective
      services).
        (4)  There  is  a reportable incident, serious reportable incident, or
      abuse allegation reported  involving  more  than  one  person  receiving
      services.
        (i)  From  a statistical point of view, the situation shall be consid-
      ered as one event.
        (ii) The agency shall establish whatever procedures it deems necessary
      to ensure that overall statistics reflect single events and  that,  when
      an event involves more than one person, records are retrievable by event
      in addition to being retrievable by a person's name.
        (e) Reporting updates.
        (1) The DDSO shall be kept informed on at least a monthly basis of the
      progress  or results of investigation of serious reportable incidents or
      allegations of abuse.
        (2) Such information may be in any form an agency chooses  such  as  a
      summary  report,  copies  of investigation reports, copies of minutes of
      review committee meetings, or an agency designed form, as  long  as  the
      following identifying and factual information is included:
        (i) Name or names of person(s) (subject(s) of the report);
        (ii) Incident/abuse report number (if applicable);
        (iii) Date of incident/allegation of abuse;
        (iv)   Classification   of  incident/allegation  of  abuse  (as  first
      reported);
        (v) Name of agency reporting,  and  name  and  address  of  any  other
      agency/facility involved;
        (vi) Name of agency investigating;
        (vii)  Corrections, changes (including reclassification of an original
      report), updates to original report, if any;
        (viii) Status (open or closed), and until closure, a brief  review  of
      findings of the investigation since submission of the last report to the
      DDSO;
        (ix)  Upon closure of an alleged abuse case, the resolution:  substan-
      tiated (see Glossary), disconfirmed (see Glossary), or inconclusive (see
      Glossary); and
        (x) Corrective and/or preventative actions taken.
 
       624.6 Notifications. 
Effective Date(s); 06/14/95 r/a 624.6; 02/08/06 amd 624.6(a); 02/08/06 amd 624.6(b)
	In addition to requiring the reporting of report-
      able  incidents,  serious reportable incidents, and allegations of abuse
      on forms as specified in section 624.5  of  this  Part,  agencies  shall
      ensure notification by appropriate means, as follows:
        (a)  For children under 18 years of age, notification of alleged abuse
      must immediately be made to the  Statewide  Central  Register  of  Child
      Abuse and Maltreatment (1-800-342-3720).
        (b)  All deaths shall be reported to the Commission on Quality of Care
      and Advocacy for Persons with Disabilities in the format as specified by
      the Commission.
        (c) All suicides, homicides,  accidental  deaths,  or  deaths  due  to
      suspicious,  unusual  or  unnatural circumstances must be reported imme-
      diately by telephone, and later in writing, to the coroner/medical exam-
      iner. In New York City, the police must also be notified.
        (d) In the case of any reportable incident, serious  reportable  inci-
      dent,  or  allegation of abuse where a crime may have been committed, it
      is the responsibility of the  chief  executive  officer  to  notify  law
      enforcement officials.
        (e) When there is reasonable cause to believe a crime against a person
      may have occurred in a facility or program of any other service provider
      licensed,  certified,  funded,  or  operated by a State Agency the chief
      executive officer of that facility or program shall be notified as  soon
      as  possible, but within three working days, unless he or she is alleged
      to have committed the crime.
        (f) A person's parent(s), guardian, or correspondent/advocate, and (if
      applicable, the service coordinator (a.k.a.  case  manager))  is  to  be
      notified of any serious reportable incident or allegation of abuse with-
      in  24  hours unless there is written advice from the parent or guardian
      that he or she does not want to be notified; unless the involved  person
      is a capable adult (see Glossary) and objects to such notification being
      made;  or  if  the  alleged abuser is one of the aforementioned parties.
      Notification of other types of events or situations shall be made at the
      chief executive officer's  discretion  and  in  accordance  with  agency
      policy/procedure.
        (1)  A  person's  parent, guardian, or correspondent/advocate shall be
      informed that he or she may request information on the actions taken  to
      protect  the  person  if  abuse  to that person is alleged to have taken
      place, unless the person is a capable adult and objects to such informa-
      tion being provided or the alleged abuser is one of  the  aforementioned
      parties. In providing such information as is requested, the agency shall
      ensure the privacy rights of other parties.
        (2)  A  person's  parent, guardian, or correspondent/advocate shall be
      informed that he or she may request information  on  the  status  and/or
      resolution  of  an abuse allegation if abuse to the person is alleged to
      have taken place, unless the person is a capable adult  and  objects  to
      such  information  being  provided  or  the alleged abuser is one of the
      aforementioned parties. In providing such information as  is  requested,
      the agency shall ensure the privacy rights of other parties.
        (f) It is the responsibility of a designated staff member of the agen-
      cy where a report on a reportable incident, serious reportable incident,
      or  allegation  of  abuse  is  received or made out, to notify any other
      agency with which the person is associated of that reportable  incident,
      serious  reportable  incident, or allegation of abuse if it has resulted
      in visible evidence of injury to the person, may be of concern to anoth-
      er agency, or may impact upon programming or activities elsewhere.
 
       624.7  Standing  committee to review and monitor reportable incidents,
     serious reportable  incidents,  and  allegations  of  abuse  to  persons
     receiving  services  from the agency. 
Effective Date(s); 06/14/95 r/a 624.7
      (a) Every agency shall have one or
     more standing committees to review  and  monitor  reportable  incidents,
     serious  reportable  incidents,  and  allegations of abuse that occur to
     people in its facilities; or to review situations which involve  any  of
     its  employees,  interns,  volunteers,  consultants, or contractors. The
     agency's organizational structure and its own policies  shall  determine
     the number of standing committees needed.
       (b)  A  standing  committee shall review reportable incidents, serious
     reportable incidents, and allegations of abuse to:
       (1) Ascertain that reportable incidents, serious reportable incidents,
     and allegations of abuse were reported, managed, investigated and  docu-
     mented consistent with the provisions of this Part and with agency poli-
     cies and procedures and to make written recommendations to the appropri-
     ate  staff  and/or  the  chief  executive officer to correct, improve or
     eliminate inconsistencies;
       (2) Ascertain that necessary and appropriate  corrective,  preventive,
     and/or  disciplinary  action has been taken to protect persons receiving
     services from further harm and to safeguard against  the  recurrence  of
     similar  reportable  incidents, serious reportable incidents, or alleged
     abuse and to make written recommendations to the chief executive officer
     to correct, improve or eliminate inconsistencies;
       (3) Ascertain if further investigation or  if  additional  corrective,
     preventive,  and/or disciplinary action is necessary, and if so, to make
     appropriate written recommendations to the chief executive officer rela-
     tive to the reportable incident, serious reportable incident, or alleged
     abuse;
       (4) Identify trends in reportable incidents, serious reportable  inci-
     dents, and/or allegations of abuse (e.g., by type, person, site, employ-
     ee  involvement,  time,  date,  circumstances,  etc.),  and to recommend
     appropriate corrective, preventive, and/or disciplinary  action  to  the
     chief  executive  officer to safeguard against such recurring situations
     or reportable incidents, serious reportable incidents,  and  allegations
     of abuse; and
       (5)  Ascertain  and  ensure the adequacy of the agency's reporting and
     review practices, including the  monitoring  of  the  implementation  of
     approved recommendations for corrective and preventive action.
       (c) A standing committee shall:
       (1)  Meet  as determined by agency policy, but no less frequently than
     on a quarterly basis and always within one month  of  the  report  of  a
     serious reportable incident or allegation of abuse, or sooner should the
     circumstances so warrant;
       (2)  Review  and  monitor  all reportable incidents that are reported,
     which may be done by a sub-committee of the  standing  committee  or  by
     individual assignment to members of the standing committee; and maintain
     a  record of such incident review, recommendations, and/or actions taken
     in such a manner as to provide for tracking and trending;
       (3) Review and monitor all serious reportable incidents and/or allega-
     tions of abuse that are reported;
       (4) Review and monitor investigatory procedures, but shall not perform
     the routine investigation of reportable  incidents,  serious  reportable
     incidents, or allegations of abuse;
       (5)  Make  recommendations, to appropriate staff to eliminate or mini-
     mize similar reportable incidents, serious reportable incidents,  and/or
     abuse situations in the future; and/or to improve investigatory or other
     procedures;
       (6)  Make  written  recommendations  to the chief executive officer on
     changes in  agency  policy  or  procedures  and  to  improve  conditions
     contributing  to the reportable incidents, serious reportable incidents,
     and/or allegations of abuse reviewed;
       (7)  Forward findings and recommendations to the chief executive offi-
     cer within two weeks of meeting;
       (8) Provide documentation that all reports of serious reportable inci-
     dents and allegations of abuse have been reviewed by the  committee  and
     that results and recommendations have been conveyed to appropriate agen-
     cy executives and others with a need to know;
       (9)  Monitor  actions  taken  on  any and all recommendations made and
     advise the chief executive officer when there is a problem;
       (10) Monitor trends of other events or situations  attributable  to  a
     person  receiving  services which may be potentially harmful, but do not
     meet the definition of being a reportable event. This may be done by the
     full committee or a  member  of  sub-committee  reporting  to  the  full
     committee;
       (11)  In  accordance  with  agency policy, report periodically, but at
     least annually, to the chief executive officer, chief agency  executive,
     the  governing  body,  and  the  DDSO concerning the committee's general
     monitoring functions; general identified trends in reportable incidents,
     serious reportable incidents, and allegations of abuse; and  corrective,
     preventive  and/or  disciplinary action pertaining to identified trends;
     and
       (12) Interact with the governing body and comply with the policies  in
     relation to the review and monitoring of all reportable incidents, seri-
     ous reportable incidents, and allegations of abuse.
       (d) Organization and membership of the standing committee.
       (1)  A standing committee or committees may be organized so as to meet
     the organizational need of an agency (e.g., on an agency-wide basis, for
     a certified class of facilities, for a grouping of certified classes  of
     facilities,  by  types  of  services  provided,  etc.). Members shall be
     appointed by the chief executive officer.
       (2) A standing committee may have other responsibilities  in  addition
     to  specified  responsibilities related to reportable incidents, serious
     reportable incidents, and allegations of abuse.
       (3) Membership of a standing committee shall include:
       (i) At least two professional staff;
       (ii) Other staff, including professional, direct care  or  administra-
     tive staff, as deemed necessary by the agency to achieve the purposes of
     the committee pursuant to this section;
       (iii)  A  physician,  physician's assistant or nurse practitioner must
     either serve on the committee or be available for  consultation  to  the
     committee;
       (iv)  Participation of a psychologist on the committee is recommended;
     and
       (v) The participation of a member(s) of the governing body is  encour-
     aged.
       (4)  Membership  limitations.  (i)  The chief executive officer of the
     agency shall not serve  as  a  member  of  the  committee,  but  may  be
     consulted by the committee in its deliberations.
       (ii)  The administrator of a class or classes of facilities or a group
     or groups of services may be designated as a member only if the  commit-
     tee  is an agency-wide or multi-program committee. If he or she is not a
     member, an administrator may be consulted by the committee in its delib-
     erations.
       (5) Case-specific requirements. (i) There shall be  representation  by
     someone from or with knowledge of the agency's own organizational entity
    where  the event, which is under discussion, occurred; or by someone who
     is familiar with the person(s) involved.
       (ii)  No committee member may participate in the review of any report-
     able incident, serious reportable incident, or alleged abuse in which he
     or she was directly involved, in which his or her testimony is  incorpo-
     rated,  in  which his or her spouse or other immediate family member was
     directly involved, or which he or she investigated  or  participated  in
     the  investigation.  Such members may, however, participate in committee
     deliberation regarding appropriate corrective or preventive action.
       (e) Minutes. The chairperson of the standing  committee  shall  ensure
     that minutes are kept for all meetings.
       (1)  Minutes  addressing  the  review of specific reportable incidents
     and/or allegations of abuse shall clearly state  the  filing  number  or
     identification  code of the report (if used), the person's full name and
     identification number (if used), and provide  a  brief  summary  of  the
     situation (including date, location and type), that caused the report to
     be  generated,  committee findings (including reclassification of event,
     if applicable), and recommendations, and actions taken on  the  part  of
     the  agency  as  a  result  of  such  recommendations. Full names of all
     parties involved are to be recorded (not initials).
       (2) Minutes are to be filed and otherwise maintained in a manner  that
     ensures confidentiality.
        624.20  Glossary.  
Effective Date(s); 06/14/95 r/a 624.20; 02/08/06 amd 624.20(m); 02/08/06 amd 624.20(q); 11/24/04 r/a 624.20(t); 
02/08/06 amd 624.20(t); 02/08/06 rel 624.20(t) to be (u); 02/08/06 rel 624.20(u) to be (t)
 The Glossary is arranged so that the last word in a title or phrase is the key 
	word to look up, and those words are arranged alphabetically.
        (a) Administrator, program. Someone designated by the  governing  body
      and/or the chief executive officer to be responsible and accountable for
      the  daily  operation  of  one  or more types of services provided by an
      agency (e.g., ICF  program,  community  residence  program,  residential
      habilitation program, respite program, family support program).
        (b)  Adult,  capable.  For purposes of this Part, a person 18 years of
      age or older who is able to understand the nature and implication of  an
      issue.  The  assessment  of  capability  in relation to each issue as it
      arises will be made by the person's program planning team  (see  Glossa-
      ry).  Capability,  as  stipulated by the definition, does not mean legal
      competency; nor does it necessarily relate to a person's  capability  to
      independently  handle  his  or  her  own  financial affairs; nor does it
      relate to the person's capacity to  understand  appropriate  disclosures
      regarding  proposed  professional  medical  treatment. Whenever there is
      doubt on the part of any other party interested in the  welfare  of  the
      person  as to that person's ability to make decisions, as ascertained by
      the program planning team or others called upon by an agency, a determi-
      nation of capability for a specific issue or issues may  be  made  by  a
      Capability  Review  Board  (see Glossary) designated by the commissioner
      except that in an ICF/MR facility the requirements of Section 681.13  of
      this Title may apply. A capable adult person cannot override the author-
      ity  granted a guardian pursuant to Article 81 of the Mental Hygiene Law
      or of a conservator or a committee; or the authority granted a  guardian
      in accordance with the Surrogate's Court Procedure Act.
        (c)  Advocate.  As  used  in this Part, someone who has volunteered to
      help a person apply for  HCBS  waiver  services  who  gives  advice  and
      support,  who  helps  the  person make informed choices, and who acts on
      behalf of the person when that person is unable to do so by  himself  or
      herself.  While an advocate plays an active role in promoting self-advo-
      cacy  and  in assisting with service planning, implementation, and moni-
      toring, he or she has no legal authority over a person's affairs  unless
      designated as the legal guardian.
        (d)  Agency. A DDSO, a not-for-profit organization (voluntary agency),
      or any other authorized entity which is the operator or administrator of
      a facility (see glossary) certified by OMRDD; or a  DDSO  which  is  the
      operator  of a developmental center. Certified family care providers are
      not considered to be an agency (see agency, sponsoring).
        (e) Agency, sponsoring. An oversight  entity  of  one  or  more  OMRDD
      certified  family  care homes. In the case of family care homes operated
      under state sponsorship, the DDSO is considered  to  be  the  sponsoring
      agency.
        (f)  Agency, State. A New York State governmental unit created for the
      management/delivery of services to the citizens of the State.
        (g) Allegation (of abuse). For purposes of this Part, the  implication
      that  abuse  of  a  person may have occurred, based upon the report of a
      witness, upon a person's own account, or upon physical evidence of prob-
      able abuse.
        (h) Assault. Based on the Penal Law in New York State,  the  following
      may be used as a guideline as to what should be reported to law enforce-
      ment  authorities: any situation where there is intent to cause physical
      injury (impairment of physical condition or substantial pain) to another
      party and such injury occurs to that party or another.
        (i) Attempt, homicide. For purposes of this  Part,  an  assault  by  a
      person in which there is apparent intent to kill.
        (j)  Board, capability review. Those designated by the commissioner or
      a DDSO director to review the ability  of  a  person  to  consent  to  a
      particular  situation when there is a dispute as to that person's abili-
      ty. Capability review board services are not available  in  Intermediate
      Care Facilities.
        (k)  Body, governing. The over-all policy-making authority, whether an
      individual or a group, that exercises general direction over the affairs
      of an agency and establishes policies concerning its operation  for  the
      welfare  of  the  persons it serves. In DDSOs and State-operated facili-
      ties, the governing body shall be the central office  administration  of
      OMRDD.  For  purposes  of  this Part, a family care home does not have a
      governing body.
        (l) Center, developmental. A class of facility designated  in  Section
      13.17  of  the  Mental  Hygiene Law and operated by the Office of Mental
      Retardation and Developmental Disabilities for the care and treatment of
      people with mental retardation and developmental disabilities.
        (m) Commission on Quality of Care and Advocacy for Persons with  Disa-
      bilities.  See  Disabilities, Commission on Quality of Care and Advocacy
      for Persons with Disabilities.
        (n) Conditioning, Aversive. Contingent upon a person's  behavior,  the
      application  to  a  person's  body  of  a physical stimulus to modify or
      change behavior with such stimulus being reasonably considered extremely
      uncomfortable or painful, or which may be noxious to the person.   Exam-
      ples  of  such  stimuli include, but are not limited to: water and other
      mists or sprays, noxious odors (e.g., ammonia),  noxious  tastes  (e.g.,
      Tabasco),  corporal  punishment  (e.g.,  slapping, spanking, hitting, or
      pinching), air blasts, blindfolds, white  noise  helmets,  and  electric
      shock.
        (o) Contact, sexual. As specified in Penal Law  130.00(3), the touch-
      ing  or  fondling  of the sexual or other intimate parts of a person not
      married to the actor for the purpose of gratifying the sexual desire  of
      either  party,  whether  directly  or through clothing. It also includes
      causing a person to touch anyone else for the  purpose  of  arousing  or
      gratifying personal sexual desires.
        (p)  Correspondent.  Someone  (not  on  the staff of the facility) who
      assists a person in obtaining necessary services,  who  participates  in
      the  person's program planning process, and who receives notification of
      certain significant events in the life of the person. The  fact  that  a
      correspondent is providing advocacy for a person as a correspondent does
      not  endow  that  individual  with  any  legal authority over a person's
      affairs.
        (q) CQAPD. See Disabilities, Commission on Quality  of  Care  for  the
      Mentally Disabled.
        (r)  Crime.  An  act  that is forbidden by law that makes the offender
      liable to punishment pursuant to that law. In New York State, the  Penal
      Law defines a crime as a Misdemeanor or a Felony, but does not include a
      traffic  infraction.  Examples of crimes are: homicide, homicide attempt
      (see Glossary), rape, public lewdness, robbery, and assault (see Glossa-
      ry).
        (s) DDSO. See Office, Developmental Disabilities Services.
        (t) Disabilities, Commission on  Quality  of  Care  and  Advocacy  for
      Persons  with  (CQCAPD).  A commission, appointed by the Governor of New
      York State in conformance with article 45 of  the  Mental  Hygiene  Law,
      whose primary function is to review the organization, administration and
      delivery  of  services  of the Office of Mental Retardation and Develop-
      mental Disabilities (OMRDD) and the Office of  Mental  Health  (OMH)  to
      ensure that the quality of care provided to persons with mental disabil-
      ities  is  of a uniformly high standard. Included in this responsibility
      is the  investigation  of  complaints  of  persons  receiving  services,
      employees  or  others,  of  allegations of abuse or mistreatment and the
      review of all deaths of persons/patients in all OMRDD and  OMH  operated
      or licensed facilities.
        (u) Disability, developmental. A disability of a person which:
        (1)(i)  is attributable to mental retardation, cerebral palsy, epilep-
      sy, neurological impairment, familiar dysautonomia or autism;
        (ii) is attributable to any other condition of a person  found  to  be
      closely related to mental retardation  because such condition results in
      similar  impairment  of  general  intellectual  functioning  or adaptive
      behavior to that of persons with mental retardation or  requires  treat-
      ment and services similar to those required for such persons; or
        (iii)   is  attributable  to  dyslexia  resulting  from  a  disability
      described in subparagraph (i) or (ii) of this paragraph;
        (2) originates before such person attains age twenty-two;
        (3) has continued or can be expected to continue indefinitely; and
        (4) constitutes a substantial handicap to  such  person's  ability  to
      function normally in society.
        (v)  Disconfirmed.  An  allegation  of  abuse was established as being
      untrue, based on available information.
        (w) Emergency. As used in this Part, a situation that  is  unexpected,
      unforeseen,  or  unanticipated and thus, no provision has been made in a
      person's plan of services through the development of a behavior  manage-
      ment plan to address how it is to be handled by staff.
        (x)  Facility.  Unless otherwise defined or modified, facility means a
      developmental center or any other  site  certified  by  OMRDD  in  which
      either  residential  or non-residential services are provided to persons
      with developmental disabilities (e.g., community residence including  an
      individualized residential alternative (IRA), intermediate care facility
      (ICF/DD),  day  treatment,  workshop, clinic, family care home, or a day
      habilitation site).
        (y) Form, Standardized. For purposes of this Part, a document or docu-
      ments specifically designed or designated by an agency for  the  purpose
      of  recording  reports of reportable incidents, serious reportable inci-
      dents, and alleged abuse (as defined herein and by  agency  policy)  for
      use  within  that agency in such a manner that there will be consistency
      of information to facilitate the investigation, review and monitoring of
      those events or situations and the corrective actions taken, as well  as
      the  identification  and  analysis of trends. A standardized form may be
      used to report other situations or events an  agency  wants  to  record,
      monitor,  and/or  trend,  in  addition  to reportable incidents, serious
      reportable incidents, or abuse allegations.
        (z) Immobilizes, totally. The  use  of  a  restraining  sheet  or  the
      complete curbing of the movement of the arms, legs, or torso through the
      use of (but limited to):
        (1)  securing  the  arms  and  legs  directly to another object (e.g.,
      straps or shackles on a chair);
        (2) Four point restraint; or
        (3) A bed sheet, towel, or similar item wrapped around a person.
        (aa) Inconclusive. It is impossible to capture sufficient  information
      which would support or disprove an abuse allegation.
        (ab)  Investigate/investigation.  That  systematic process whereby the
      circumstances surrounding an event/situation are  examined  and  scruti-
      nized,  whether  by  a  chief  executive officer, designated staff, or a
      trained investigator (see Glossary). The intensity of any  investigation
      is decided by the event/situation under study.
        (ac) Investigator. That party or parties, designated by agency policy,
      responsible  for  collecting information to establish the facts relative
      to an event/situation, whether immediately following  or  subsequent  to
      that  event/situation.  While  an  investigator  need  not  be  a person
      appointed to a position bearing that title or  have  highly  specialized
      training  in investigatory techniques, it is recommended that the inves-
      tigation of allegations of abuse be conducted by an individual  skilled,
      by  virtue  of  training  or  experience,  in the appropriate techniques
      necessary to bring such allegations to a satisfactory conclusion.
        (ad) Member, senior staff. As used in this Part, that staff member, by
      whatever title he or she may be known, who is  designated  as  a  senior
      member  of  the administrative structure of an agency, and, as such, may
      carry out designated responsibilities delegated to the  chief  executive
      officer.  This  may be someone who is responsible for a group of facili-
      ties (e.g., program administrator), or who is immediately in charge of a
      facility or of a designated  area  (e.g.,  residence  manager,  head  of
      shift,  unit  supervisor).  In  conformance with the Mental Hygiene Law,
      section 33.04, such senior staff members may also be designated  by  the
      chief  executive  officer as having the authority to impose a mechanical
      restraining device in an emergency, when appropriately trained in  their
      use and application.
        (ae)  Office,  Developmental  Disabilities  Services (DDSO). The local
      administrative unit of OMRDD responsible for  coordinating  the  service
      delivery system within a particular service area.
        (af)  Officer,  Chief  Executive.  Someone  (by whatever name or title
      known) designated by the governing body (see glossary) with overall  and
      ultimate  responsibility  for  the  operation  of one or more classes of
      facility, for the delivery of other services to  persons  with  develop-
      mental disabilities, and with control over any and all equipment used in
      the  care  and  treatment  of  such persons; or a designee with specific
      responsibilities as specified in agency policy/procedure. In a  develop-
      mental center and/or DDSO, this party is referred to as the director.
        (ag)  Person/persons. For purposes of this Part, a child or adult with
      a diagnosis of developmental disability, who has been or is being served
      by a state, private, or voluntary operated facility certified by OMRDD.
        (ah) Procedures, formal search. A systematic process involving employ-
      ees  with  specific  responsibilities  (e.g.  security  personnel),  law
      enforcement  agencies,  and  any  others designated by agency policy and
      which is initiated for the purpose of locating a person who has not been
      found in response to an informed search.
        (ai) Provider, family care. One of more adults age 21 or over to  whom
      an  operating  certificate  has been issued by OMRDD to operate a family
      care home. A family care provider is an independent contractor.
        (aj) Purposes, (devise for) medical. A mechanical  restraining  device
      which  controls  movement  and  which  is  prescribed  by a physician or
      dentist to facilitate a specific medically necessary procedure;  or  for
      time limited periods for explicit medical reasons during healing.  Exam-
      ples of devices used during healing would include a brace to keep a limb
      in  place,  splints  or  braces  to  provide stability for broken bones,
      devices to prevent or avoid irritation  or  further  injury  of  a  skin
      ailment or burn, and traction equipment.
        (ak)  Service, Mental Hygiene Legal (MHLS). A service of the appellate
      division of the State Supreme Count established pursuant to  Article  47
      of  the Mental Hygiene Law. (Formerly, Mental Health Information Service
      - MHIS).
        (al) Services, plan of. An individualized record system,  by  whatever
      name  known,  which  documents  the process of developing, implementing,
      coordinating, reviewing, and modifying a person's total plan of care. It
      is maintained as the functional record indicating all planning  as  well
      as  services and interventions provided to the person. It contains, at a
      minimum, identification data, diagnostic reports,  assessments,  service
      plans,  medical  data, activity schedules, program planning team minutes
      and reports, staff action records, and information on efforts  to  place
      people  in  a less restrictive level of programming. Such record is also
      known as the "clinical record" in Part 636 of this Title.
        (am) Substantiated. An alleged abuse was confirmed.
        (an) Supports. Those mechanical  restraining  devices,  ordered  on  a
      least  an  annual  basis  by a physician in consultation with a person's
      program planning team, needed  to  assist  the  person  in  his  or  her
      comfort,  functioning,  and/or  safety. Supports approved by the Commis-
      sioner are:
        (1) Devices which maintain a person's body in good alignment.
        (2) Devices which maintain a person in a safe and/or appropriate posi-
      tion when a person is not capable of self-support or self-ambulation.
        (3) Devices (such as helmets) which protect the head of a person  with
      a health problem (e.g., seizures) that necessitates such a safeguard.
        (ao)  Team, program planning. Those, by whatever name known, acting as
      a unit, responsible for identifying a person's  needs;  for  developing,
      implementing  and  evaluating  the plan of services for that person; and
      ensuring that  the  current  setting  and/or  services  currently  being
      received continue to be appropriate. Regulations for a specific class of
      facility  are  to be referenced for specific details. For those enrolled
      in the Home and Community -Based waiver  (HCBS),  the  program  planning
      team  is  defined  as the person (consumer) and the waiver case manager,
      and the advocate (if appropriate) as well as any other party or  parties
      considered, at any given time, as being appropriate for participation by
      that group.
        (ap) Time-out. A behavior management intervention in which a person is
      temporarily  removed from or denied the opportunity to obtain reinforce-
      ment and during which the person is under visual or auditory contact and
      supervision. When a room is used for time-out  purposes,  normal  egress
      from  that  room  can only be prevented by the direct physical action of
      appropriately trained staff and when such  action  is  designated  in  a
      written  plan.  The placement of a person in a secured room or area from
      which he or she cannot leave at will, for  other  than  the  purpose  of
      time-out,  is  prohibited and is considered to be a form of abuse. Time-
      out is not considered to be a form of aversive conditioning (see glossa-
      ry).
        (aq) Treatment, requiring medical or dental. That situation whereby  a
      person  who,  by virtue of his or her condition as a result of a report-
      able incident or serious reportable  incident,  must  see  a  physician,
      dentist, physician's assistant, or nurse practitioner to have the condi-
      tion  diagnosed,  controlled and/or attended to with more than first-aid
      procedures. While individual agency policy/procedure may direct  that  a
      person  who  is in any way injured or has suffered any ill effects is to
      see  a  medical  professional  even  though  first-aid  has   adequately
      addressed  the  situation,  this  does  not  always constitute requiring
      medical or dental treatment in terms of defining a  reportable  incident
      or  serious  reportable  incident.  If  there is a diagnostic procedures
      (e.g., x-ray) are performed, this would constitute an  injury  requiring
      medical  or  dental  treatment  and would be reported as a reportable or
      serious incident. If a person is detained in a  hospital  overnight  for
      observation,  this would be a situation that required medical treatment,
      and be reported as a serious reportable incident.
 
COPY OF FORM OMR 147(I)- REPORTABLE INCIDENT MAY BE OBTAINED FROM OMR
COPY OF FORM OMR 147 (A)- ALLEGATION OF CLIENT ABUSE MAY BE OBTAINED FROM OMR