5122-26-13 Incident notification and risk management.

(A) This rule establishes standards to ensure the prompt and accurate notification of certain prescribed incidents. It also requires the agency to review and analyze all incidents so that it might identify and implement corrective measures designed to prevent recurrence and manage risk.

(B) Definitions

(1) "County community mental health board of residence" means the mental health board that is responsible for referring and/or paying for the client's treatment.

(2) "Incident" means an event that poses a danger to the health and safety of clients and/or staff and visitors of the agency, and is not consistent with routine care of persons served or routine operation of the agency.

(3) "Reportable Incident" means an incident that must be submitted to the department, including an incident that must then be forwarded by the department to the Ohio legal rights service pursuant to section 5123.604 of the Revised Code. As referenced in division (C) of section 5119.611 of the Revised Code, "Major Unusual Incident" has the same meaning as "Reportable Incident."

(4) "Six month reportable incident" means an incident type of which limited information must be reported to the department. A six month reportable incident is not the same as a reportable incident.

(5) "Six month incident data report" means a data report which must be submitted to the department.

(C) The agency shall develop an incident reporting system to include a mechanism for the review and analysis of all reportable incidents such that clinical and administrative activities are undertaken to identify, evaluate, and reduce risk to clients, staff, and visitors. The agency shall identify in policy other incidents to be reviewed and analyzed.

(1) An incident report shall be submitted in written form to the agency's executive director or designee within twenty-four hours of discovery of a reportable incident.

(2) As part of the agency's performance improvement process, a periodic review and analysis of reportable incidents, and other incidents as defined in agency policy, shall be performed. This shall include a review of all incident reports received from licensed type 2 and type 3 residential facilities regarding persons served by the agency, and any action taken by the agency, as appropriate.

(3) The agency shall maintain an ongoing log of its reportable incidents for departmental review.

(D) Any person who has knowledge of any instance of abuse or neglect, or alleged or suspected abuse or neglect of:

(1) Any child or adolescent, shall immediately notify the county children's services board, the designated child protective agency, or law enforcement authorities, in accordance with section 2151.421 of the Revised Code; or

(2) An elderly person, shall immediately notify the appropriate law enforcement and county department of jobs and family services authorities in accordance with section 5101.61 of the Revised Code.

(E) Each agency shall submit reportable incidents and six month reportable incidents as defined by and according to the schedule included in appendix A to this rule.

(F) Each reportable incident shall be documented on form "DMH-LIC-015" as required by the department. Form "DMH-LIC-015" shall include identifying information about the agency, date, time and type of incident, and client information that has been de-identified pursuant to the HIPAA privacy regulations, [ 45 C.F.R. 164.514(b)(2) ].

(1) The agency shall file only one incident form per event occurrence and identify each incident report category, if more than one, and include information regarding all involved clients, staff, and visitors; and

(2) The agency shall forward each reportable incident to the department and to the county community mental health board of residence within twenty-four hours of its discovery, exclusive of weekends and holidays; and

(G) Each agency shall submit a six month incident data report to the department and to the community mental health board utilizing the form that is in appendix B to this rule.

The six month incident data report must be submitted according to the following schedule:

(1) The six month incident data report for the period of January first to June thirtieth of each year shall be submitted no later than July thirty-first of the same year; and

(2) The six month incident data report for the period of July first to December thirty-first of each year shall be submitted no later than January thirty-first of the following year.

(H) The department may initiate follow-up and further investigation of a reportable incident and six month reportable incidents, as deemed necessary and appropriate, or may request such follow-up and investigation by the agency, regulatory or enforcement authority, and/or the community mental health board.

Replaces: 5122-26-13

Click to view Appendix

Click to view Appendix

Effective: 01/01/2012
R.C. 119.032 review dates: 01/01/2017
Promulgated Under: 119.03
Statutory Authority: 5119.61, 5119.611
Rule Amplifies: 5119.61, 5119.611
Prior Effective Dates: 1/1/04