Rule 5160-26-14 | Medicaid managed care organizations: incident management.
This rule does not apply to the Ohio resilience through integrated systems and excellence (OhioRISE) plan as defined in rule 5160-59-01 of the Administrative Code. This rule sets the standards and procedures for managing incidents that may have a negative impact on medicaid managed care and MyCare Ohio members. The purpose of this rule is to establish the procedures for reporting and addressing critical incidents and to prevent and reduce the risk of harm to members. The Ohio department of medicaid (ODM) may designate other entities to perform one or more of the incident management functions set forth in this rule.
(A) For the purposes of this rule, the following definitions apply:
(1) "Incident" means as defined in rule 5160-44-05 of the Administrative Code.
(2) "Incident management system" means as defined in rule 5160-44-05 of the Administrative Code.
(3) "Restraint" means as defined in rule 5160-45-01 of the Administrative Code.
(4) "Restrictive intervention" means as defined in rule 5160-45-01 of the Administrative Code.
(5) "Seclusion" means as defined in rule 5160-45-01 of the Administrative Code.
(6) "Substantiated" means as defined in rule 5160-44-05 of the Administrative Code.
(7) "Unauthorized restraint" means as defined in rule 5160-44-05 of the Administrative Code.
(8) "Unauthorized restrictive intervention" means as defined in rule 5160-44-05 of the Administrative Code.
(9) "Unauthorized seclusion" means as defined in rule 5160-44-05 of the Administrative Code.
(B) The following incidents defined in paragraph (B) of rule 5160-44-05 of the Administrative Code will be reported and investigated as described in paragraph (D) of this rule:
(1) Abuse.
(2) Behavioral support misuse.
(3) Neglect.
(4) Exploitation.
(5) Misappropriation.
(6) Unnatural or accidental death.
(7) Self-harm or suicide attempt.
(8) Medication error.
(C) Populations of members to which this rule applies.
(1) Members enrolled in a medicaid managed care organization (MCO) as defined in rule 5160-26-01 of the Administrative Code, but not also enrolled in a nursing facility-based level of care home and community-based services (HCBS) waiver program.
Incidents discovered by an MCO for a member enrolled in a nursing facility-based level of care HCBS waiver program are reported to the administering agency per rule 5160-44-05 of the Administrative Code.
(2) Members enrolled in a MyCare Ohio plan (MCOP) as defined in rule 5160-58-01 of the Administrative Code, but not also enrolled in a nursing facility-based level of care HCBS waiver program or the specialized recovery services program (SRSP).
Incidents discovered by an MCO for a member enrolled in a nursing facility-based level of care HCBS waiver program or the SRSP are reported to the administering agency per rule 5160-44-05 of the Administrative Code.
(D) The following process will be followed upon the occurrence of an incident.
(1) Initial incident report.
(a) Upon discovering an incident, ODM, its delegates, and providers of services under contract with an MCO or MCOP will:
(i) Take immediate action to ensure the health and welfare of the member.
(ii) Report the incident to the relevant MCO or MCOP immediately upon discovery of the incident, but no later than one business day after discovering the incident, unless bound by federal, state, or local law, or the requirements of professional licensure or certification to report sooner.
(b) All incident reports will include the following information when available:
(i) The facts relevant to the incident;
(ii) A description of the incident;
(iii) The incident type;
(iv) The date of the incident;
(v) The location of the incident;
(vi) The names and contact information of all persons involved; and
(vii) All actions taken to ensure the health and welfare of the member.
(2) Receipt of report and documentation of the incident.
(a) The MCO, MCOP, or their designee will do the following upon discovering or receiving a report of an incident.
(i) Ensure immediate action was taken to protect the health and welfare of the member. If such action was not taken, take action immediately, but no later than twenty-four hours after the report was received.
(ii) Notify all of the appropriate entities with investigative or protective authority, and the appropriate additional regulatory, oversight, or advocacy agencies, including but not limited to:
(a) Local law enforcement if the incident involves suspected criminal conduct;
(b) The local coroner's office when the death of a member is reportable in accordance with section 313.12 of the Revised Code;
(c) The local county board of developmental disabilities;
(d) The local child protective services agency (CPS);
(e) The local adult protective services agency (APS);
(f) The Ohio department of health, or other licensure or certification board or accreditation body if the incident involves a provider regulated by that entity;
(g) The local probate court if the incident may involve the legal guardian of the recipient.
(b) Enter all critical incidents into the incident management system within one business day of becoming aware of the incident.
(3) Incident investigation.
(a) The MCO, MCOP, or their designee will investigate all critical incidents by doing the following:
(i) Within two business days of entering the incident into the incident management system, initiate an investigation.
(ii) Conduct a review of all relevant documents including individualized service plans, care plans, assessments, clinical notes, communication notes, results from an investigation conducted by a third-party entity when available, provider documentation, provider billing records, medical reports, police and fire department reports, and emergency response system reports.
(iii) Conduct and document interviews with everyone who may have information relevant to the incident including.
(iv) Identify, to the extent possible, all causes and contributing factors.
(v) Determine whether the incident is substantiated.
(vi) Document all investigative activities in the incident management system.
(vii) Conclude the investigation no later than forty-five business days after the documented start date of the investigation, unless a longer time frame has been previously approved by ODM.
(4) Follow-up and closeout responsibilities.
(a) For incidents that resulted in a CPS or APS referral, communicate a summary of the investigative findings to the relevant agency within seven business days after being notified that the investigation is complete.
(b) For substantiated incidents, except in the case of death, enter a prevention plan into the incident management system no later than seven business days after the conclusion of the investigation, indicating closure of the incident.
(E) ODM may request further review of any incident, conduct a separate independent review or investigation of any incident, determine additional action, or assume responsibility for conducting an investigation or review.
Last updated August 27, 2026 at 8:02 AM
Supplemental Information