2006 New York Code - Incident Reporting Procedures
§ 29.29 Incident reporting procedures. The commissioners of the offices of mental health and mental retardation and developmental disabilities of the department shall establish policies and uniform procedures for their respective offices for the compilation and analysis of incident reports. Incident reports shall, for the purposes of this chapter, mean reports of accidents and injuries affecting patient health and welfare at such departmental facilities. These policies and procedures shall include but shall not be limited to: 1. The establishment of a patient care and safety team at the facility level which shall include but not be limited to a: physician, nurse, social worker and therapy aide, to investigate and report to the facility director on: (i) suicides or attempted suicides; (ii) violent behavior exhibited by either patients or employees; (iii) frequency and severity of injuries incurred by either patients or employees; (iv) frequency and severity of injuries occurring on individual wards or in buildings at such facility; (v) patient leave without consent; or (vi) medication errors. 2. The establishment of cumulative record keeping of incident reports which identifies patient and employee involvement. 3. A compilation of uniform and measurable information, first on a facility basis, then on an office-wide basis, that will indicate where the greatest number and types of incidents of violence and injury occur. 4. That each facility shall aggregate its data monthly for the director and that aggregated information shall be submitted, at least semi-annually to the commissioner of the office of mental health by facilities listed in section 7.17 of this chapter, and to the commissioner of the office of mental retardation and developmental disabilities by facilities listed in section 13.17 of this chapter. 5. Such commissioners shall transmit a copy of any report received pursuant to subdivision four of this section to the state commission on quality of care for the mentally disabled. 6. Such commissioners shall promulgate regulations establishing standards for the protection of children in residential care from abuse and maltreatment, including procedures for: (a) consistent with appropriate collective bargaining agreements and applicable provisions of the civil service law, the review and evaluation of the backgrounds of and information supplied by any person applying to be an employee, a volunteer or consultant, which shall include but not be limited to the following requirements: that the applicant set forth his or her employment history, provide personal and employment references and relevant experiential and educational information and, sign a sworn statement whether, to the best of his or her knowledge, he or she has ever been convicted of a crime in this state or any other jurisdiction; (b) establishing for employees, minimal experiential and educational qualifications consistent with appropriate collective bargaining agreements and applicable provisions of the civil service law; (c) assuring adequate and appropriate supervision of employees, volunteers and consultants; (d) demonstrating that appropriate action is taken to assure the safety of the child who is reported to the state central register as well as other children in care, immediately upon notification that a report of child abuse or maltreatment has been made with respect to a child's custodian in a residential facility; (e) removing a child when it is determined that there is risk to such child if he or she continues to remain in a residential facility; and (f) appropriate preventive and remedial action to be taken including legal action, consistent with appropriate collective bargaining agreements and applicable provisions of the civil service law. Such standards shall also establish as a priority that: (i) subject to the amounts appropriated therefor, administrators, employees, volunteers and consultants receive training in at least the following: child abuse prevention and identification, safety and security procedures, the principles of child development, the characteristics of children in care and techniques of group and child management including crisis intervention, the laws, regulations and procedures governing the protection of children from abuse and maltreatment, and other appropriate topics provided, however, that such offices may exempt administrators and consultants from such requirements upon demonstration of substantially equivalent knowledge or experience; and (ii) subject to the amounts appropriated therefor, children receive instruction, consistent with their age, needs and circumstances as well as the needs and circumstances within the facility or program, in techniques and procedures which will enable such children to protect themselves from abuse and maltreatment. The commissioners shall take all reasonable and necessary actions to assure that employees, volunteers or consultants in residential care facilities are kept apprised on a current basis of all policies and procedures of the respective offices relating to the protection of children from abuse and maltreatment, and shall monitor and supervise the provision of training to such administrators, employees, volunteers, children and consultants. Standards developed pursuant to this subdivision shall, to the extent possible, be consistent with those promulgated by other state agencies for such purposes. 7. Such commissioners shall provide necessary assistance to the state commission on quality of care for the mentally disabled in the conduct of investigations pursuant to section 45.07 of this chapter, shall consider its recommendations for appropriate preventive and remedial action including legal actions, and shall provide or direct a residential facility licensed or operated by the office of mental health or office of mental retardation and developmental disabilities to provide written reports thereon to the commission as to the implementation of plans of prevention and remediation. 8. Such commissioners shall provide for the development and implementation of a plan of prevention and remediation with respect to an indicated report of child abuse or maltreatment. Such action shall include: (a), within ten days of receipt of an indicated report of child abuse or maltreatment, development and implementation of a plan of prevention and remediation to be taken with respect to a custodian or residential facility in order to assure the continued health and safety of children and to provide for the prevention of future acts of abuse or maltreatment; and (b) development and implementation of a plan of prevention and remediation, in the event an investigation of a report of alleged child abuse or maltreatment determines that some credible evidence of abuse or maltreatment exists and such abuse or maltreatment may be attributed in whole or in part to noncompliance by the facility with provisions of this chapter or regulations of the respective offices applicable to the operation of such residential facility. Any plan of prevention and remediation required to be developed pursuant to paragraph (b) of this subdivision by a facility supervised by either office shall be submitted to and approved by such office in accordance with time limits established by regulations of such office. Implementation of the plan shall be monitored by such office. In reviewing the continued qualifications of a residential facility or program for an operating certificate, the office having supervisory responsibilities shall evaluate such facility's compliance with plans of prevention and remediation developed and implemented pursuant to this subdivision.
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