55 Pa. Code § 2390.18 - Incident report and investigation
(a) The facility shall report the following
incidents, alleged incidents and suspected incidents through the Department's
information management system or on a form specified by the Department within
24 hours of discovery by a staff person:
(1)
Death.
(2) A physical act by a
client in an attempt to complete suicide.
(3) Inpatient admission to a
hospital.
(4) Abuse, including
abuse to a client by another client.
(5) Neglect.
(6) Exploitation.
(7) A client who is missing for more than 24
hours or who could be in jeopardy if missing for any period of time.
(8) Law enforcement activity that occurs
during the hours of facility operation.
(9) Injury requiring treatment beyond first
aid.
(10) Fire requiring the
services of the fire department. This provision does not include false
alarms.
(11) Emergency
closure.
(12) Theft or misuse of
client funds.
(13) A violation of
client rights.
(b) The
facility shall report the following incidents, alleged incidents and suspected
incidents through the Department's information management system or on a form
specified by the Department within 72 hours of discovery by a staff person:
(1) Use of a restraint.
(2) A medication error as specified in §
2390.196 (relating to medication
errors), if the medication was ordered by a health care
practitioner.
(c) The
client and persons designated by the client shall be notified within 24 hours
of discovery of an incident relating to the client.
(d) The facility shall keep documentation of
the notification in subsection (c).
(e) The incident report, or a summary of the
incident, the findings and the actions taken, redacted to exclude information
about another client and the reporter, unless the reporter is the client who
receives the report, shall be available to the client and persons designated by
the client, upon request.
(f) The
facility shall take immediate action to protect the health, safety and
well-being of the client following the initial knowledge or notice of an
incident, alleged incident or suspected incident.
(g) The facility shall initiate an
investigation of an incident, alleged incident or suspected incident within 24
hours of discovery by a staff person.
(h) A Department-certified incident
investigator shall conduct the investigation of the following incidents:
(1) Death that occurs during the provision of
service.
(2) Inpatient admission to
a hospital as a result of an accidental or unexplained injury or an injury
caused by a staff person, another client or during the use of a
restraint.
(3) Abuse, including
abuse to a client by another client.
(4) Neglect.
(5) Exploitation.
(6) Injury requiring treatment beyond first
aid as a result of an accidental or unexplained injury or an injury caused by a
staff person, another client or during the use of a restraint.
(7) Theft or misuse of client
funds.
(8) A violation of client
rights.
(i) The facility
shall finalize the incident report through the Department's information
management system or on a form specified by the Department within 30 days of
discovery of the incident by a staff person unless the facility notifies the
Department in writing that an extension is necessary and the reason for the
extension.
(j) The facility shall
provide the following information to the Department as part of the final
incident report:
(1) Additional detail about
the incident.
(2) The results of
the incident investigation.
(3)
Action taken to protect the health, safety and well-being of the
client.
(4) A description of the
corrective action taken in response to an incident and to prevent recurrence of
the incident.
(5) The person
responsible for implementing the corrective action.
(6) The date the corrective action was
implemented or is to be implemented.
Notes
The provisions of this § 2390.18 amended under sections 201(2), 403(b), 403.1(a) and (b), Articles IX and X of the Human Services Code (62 P.S. §§ 201(2), 403(b), 403.1(a) and (b), 901-922 and 1001-1088); and section 201(2) of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § 4201(2)).
This section cited in 55 Pa. Code § 2390.196 (relating to medication errors).
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