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
624.2 Background and intent
624.3 Statutory authority
624.4 Reportable incidents, serious reportable incidents and abuse,
624.5 Reporting, recording and investigation
624.7 Standing committee to review and monitor reportable incidents,
serious reportable incidents, and allegations of abuse to
persons receiving services from the agency
| 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