Incident Reporting: Policies and Procedures
General Definitions of Incidents and Abuse
POLICY:
Ontario ARC is committed to protecting persons who attend our programs or receive support.. Parts 624 NYCRR and NYCRR Part 625 describe the requirements for reporting, documenting, investigating and reviewing events that affect the safety and welfare of people we support. Adherence to these regulations is required of all staff members at all times. No occurrences of mistreatment or abuse will be tolerated at Ontario ARC, under any circumstance.
In addition, Social Services law 702 requires that all staff, volunteers, and contractors are “custodians” and mandated to report any allegations of abuse or significant incidents to the New York State Justice Center for the protection of people with Special Needs.
Ontario ARC does not condone the use of Time Out or Aversive Conditioning under any circumstances. Substantiated allegations of such will result in supervisory action up to and including termination of employment. Further, Ontario ARC is committed to the protection of people supported, and will notify Law Enforcement upon receipt of an allegation or report that an individual was intentionally harmed in any way.
VALUES
Quality
Quality of Life
Definitions: (Under Agency Auspices)
By general definition, a "Reportable Incident" is any significant event or situation which endangers the well-being of a person receiving services no matter if the cause was accidental, caused by the person himself/herself, or caused by another person. “Reportable Incidents” are events that occur under the auspices of the agency, and must be reported to OPWDD and the Justice Center (when occurring in a certified setting).
A "Reportable Incident – Abuse/Neglect" includes physical abuse, psychological abuse, sexual abuse, deliberate inappropriate use of restraints, aversive conditioning, obstruction of reports of reportable incidents, unlawful use or administration of a controlled substance and Neglect. Broadly defined, these subcategories include maltreatment or mishandling of a person receiving services which endangers the physical or emotional well-being of the person through the action or inaction of a staff person, a volunteer, or another individual whether or not the person appears to be injured or harmed. The failure to intercede on behalf of a person is also considered abuse. When the abuse involves two people receiving services, it is necessary to take into account the aggressor's judgment and cognitive abilities to determine whether the act is an abuse allegation or a behavioral problem.
A "Reportable Incident-Significant Incident" is one which, because of its severity or the sensitivity of the situation may result in, or has the reasonably foreseeable potential to result in, harm to the health, safety, or welfare of a person receiving services, and includes but is not limited to: conduct between individuals receiving services, which results in treatment greater than first aid, seclusion, unauthorized use of time out, medication errors with adverse effect, inappropriate use of restraints, mistreatment, missing persons, unauthorized absences, choking with known risk, chocking with no known risk, self-abusive behavior with injury, theft or financial exploitation (great than $100 or use of a benefit, credit or debit card), or other significant incidents not otherwise specified above.
“Serious Notable Occurrences” include death, which are reported immediately to the NYS Justice Center and within 24 hours to OPWDD, as well as sensitive situations (those situations that do not meet the definitions of other incidents referenced above) and which also must be reported to OPWDD.
“Minor Notable Occurrences” are events that do not meet the criteria above, however, occur in under the auspices of the agency and could result in harm to the individuals we support. Minor Notable Occurrences include injuries requiring more than first aid and theft or financial exploitation (involving values of more than $15 and less than or equal to $100, and which do not involve a credit, benefit or debit card). Minor Notable Occurrences are reported internally.
Specific classifications and definitions for reportable incidents, serious notable occurrences and minor notable occurrences, as contained in Parts624 and 625 of NYS Mental Hygiene Law, are summarized in the following section. These should be used as guidelines by all staff. Complete copies of Parts 624 and 625 are available on the agency staff website and can be referred to, when necessary.
There are other types of events which, by this agency's standards, are to be reported as incidents. These include the use of life-saving techniques (Abdominal thrust, CPR), vehicle accidents with no injuries while participants are using agency transportation or staff vehicles, and in some cases, participant-to-participant confrontations or rights violations. Events such as these are to be initially handled, reported, reviewed and then monitored as agency incidents, though not included in Part 624 or 625.
Specific Definitions
REPORTABLE INCIDENTS – ABUSE/NEGLECT
Physical Abuse
Physical Abuse shall mean conduct by a custodian intentionally or recklessly causing, by physical contact, physical injury or serious protracted impairment of the physical, mental, or emotional condition of the individual receiving services, or causing the likelihood of such injury or impairment. Such conduct may include, but shall not be limited to: slapping, hitting, kicking, biting , choking, smothering, shoving, dragging, throwing, punching, shaking, burning, cutting, or the use of corporal punishment. Physical abuse shall not include reasonable emergency interventions necessary to protect the safety of any party. An unauthorized or unnecessary or improperly used physical intervention (Positive Approaches 3) technique also constitutes abuse.
Sexual Abuse
Sexual Abuse shall mean any sexual contact between a person receiving services and staff, consultant, contractor or volunteer. Sexual contact includes touching or fondling of the sexual or other intimate parts of a person receiving services directly or through clothing for the purpose of sexual arousal or sexual gratification. Also, causing a person receiving services to engage in any act considered sexual in nature.
Psychological Abuse (Emotional Abuse)
Any verbal or nonverbal conduct that may cause significant emotional distress to an individual receiving supports. Examples include (but are not limited to) taunting, derogatory comments or ridicule, intimidation, threats or the display of a weapon or other object that could reasonably be perceived by an individual receiving supports as a means for infliction of pain or injury, in a manner that constitutes a that of physical pain or injury.
In order for a case of psychological abuse to be substantiated after it has been reported, the conduct, must be shown to intentionally or recklessly cause, or be likely to cause, a substantial diminution of the emotional, social, or behavioral development or condition of the individual receiving services. Evidence of such an effect must be supported by a clinical assessment performed by a physician, psychologist, psychiatric nurse practitioner, licensed clinical or master social worker, or licensed mental health counselor.
Deliberate Inappropriate Use of Restraint
The use of a restraint when the technique used, the amount of force used, or the situation in which the restraint is used is deliberately inconsistent with an individual’s plan or services, or behavior support plan, generally accepted treatment practices, and/or applicable federal or state laws, regulations, or policies, except when the restraint is used as a reasonable emergency intervention to prevent imminent risk of harm to a person receiving services or to any other party. For purposes of this paragraph, a restraint includes the use of any manual, pharmacological, or mechanical measure or device to immobilize or limit the ability of a person receiving services to freely move his or her arms, legs, or body.
Use of Aversive Conditioning
The application or physical stimulus that is intended to induce pain or discomfort in order to modify or change the behavior of a person receiving services. Aversive Conditioning may include, but is not limited to, the use of physical stimuli such as noxious odors, noxious tastes, blindfolds, sleep deprivation, food deprivation and food alteration for disciplinary purposes, the convenience or staff, or as a consequence of challenging behavior. Ontario ARC does not condone or tolerate any use of Aversive Conditioning.
Obstruction of Reports of Reportable Incidents.
Conduct by a custodian that impedes the discovery, reporting, or investigation of the treatment of a service recipient by falsifying records related to the safety, treatment or supervision of an individual receiving services; actively persuading a custodian or other mandated reporter from making a report to the Justice Center or OPWDD. Intentionally making a false statement or intentionally withholding information; intentional failure of a supervisor or manager to act upon such a report.
Unlawful Use or Administration of a Controlled Substance
Any administration by a custodian to a service recipient of a controlled substance without a prescription, or other medication not approved for any use by the federal food and drug administration. It also shall include a custodian unlawfully using or distributing a controlled substance at the workplace or while on duty.
REPORTABLE INCIDENTS – SIGNIFICANT INCIDENTS
Conduct Between Individuals Receiving Services
Conduct that would constitute abuse if committed by a custodian and if more than first aid is necessary.(This must be intentional abuse against a peer.)
Seclusion
The placement of an individual receiving services in a room or area from which he or she cannot,
or perceives that he or she cannot, leave at will.
Unauthorized Use of Time Out
Means the use of a procedure in which a person receiving services is removed from regular programming and isolated in a room or area for the convenience of a custodian, for disciplinary purposes, or as a substitute for programming.
Medication Error with Adverse Effect
The administration of a prescribed or over-the-counter medication that is inconsistent with a prescription or order issued for a service recipient by a licensed qualified health care practitioner, and that has an adverse effect on an individual receiving services. For purposes of this clause, "adverse effect" means the unanticipated and undesirable side effect from the administration of a particular medication which unfavorably affects the wellbeing of a person receiving services.
Inappropriate Use of Restraints
The use of a restraint when the technique that is used, the amount of force that is used, or the situation in which the restraint is used is inconsistent with an individual’s plan of services (including a behavior support plan), generally accepted treatment practices, and/or applicable federal or state laws, regulations, or policies. For the purposes of this subdivision, a "restraint" includes the use of any manual, pharmacological, or mechanical measure or device to immobilize or limit the ability of a person receiving services to freely move his or her arms, legs, or body.
Mistreatment
Other conduct on the part of a custodian, inconsistent with the individual’s plan of services, generally accepted treatment practices, and/or applicable federal or state laws, regulations, or policies, and that impairs or creates a reasonably foreseeable potential to impair the health, safety, or welfare of an individual receiving services, except as described in any other provision of this subdivision.
Missing Person
The unexpected absence of individual receiving services that based on the person's history and current condition exposes him or her to risk of injury.
Unauthorized Absence
The unexpected or unauthorized absence of a person after formal search procedures has been initiated by the agency. Reasoned judgments, taking into consideration the person's habits, deficits, capabilities, health problems, etc., determine when formal search procedures need to be implemented. It is required that formal search procedures must be initiated immediately upon discovery of an absence involving a person whose absence constitutes a recognized potential danger to the wellbeing of the person or others.
Choking, with Known Risk
The partial or complete blockage of the upper airway by an inhaled or swallowed foreign body, including food that leads to a partial or complete inability to breathe involving an individual with a known risk for choking and a written directive addressing that risk.
Choking with No Known Risk
For the purposes of this paragraph, partial or complete blockage of the upper airway by an inhaled or swallowed foreign body, including food that leads to a partial or complete inability to breathe, other than a choking, with known risk, incident involving an individual with a known risk for choking and a written directive addressing that risk
Self-Abusive Behavior, with Injury
A self-inflicted injury to individual receiving services that requires medical care beyond first aid.
Injury with Hospital Admission
An injury that results in the admission of a service recipient to a hospital for treatment or observation.
Theft and Financial Exploitation
Any suspected theft of a service recipient's personal property (including personal funds or belongings) or financial exploitation, involving a value of more than $100.00; theft involving a service recipient's credit, debit, or public benefit card (regardless of the amount involved); or a pattern of theft or financial exploitation involving the property of one or more individuals receiving services.
Other Significant Incident
An incident that occurs under the auspices of an agency, but that does not involve conduct on the part of a custodian, and does not meet the definition of any other incident described in this subdivision, but that because of its severity or the sensitivity of the situation may result in, or has the reasonably foreseeable potential to result in, harm to the health, safety, or welfare of a person receiving services.
SERIOUS NOTABLE OCCURRENCE
Death
The death of any person receiving services, regardless of the cause of death. This includes all deaths of individuals who live in residential facilities operated or certified by OPWDD and other deaths that occur under the auspices of an agency.
Sensitive Situation
Situations involving a person supported that do not meet the criteria of definitions above, which may be of a delicate nature to the agency and which are reported to ensure awareness of the circumstances. May include Possible Criminal Acts committed by a person supported.
MINOR NOTABLE OCCURRENCES
Theft or Financial Exploitation
Any suspected theft of a service recipient's personal property (including personal funds or belongings) or financial exploitation, involving values of more than $15.00 and less than or equal to $100.00, that does not involve a credit, debit, or public benefit card, and that is an isolated event.
Injury
Any suspected or confirmed harm, hurt, or damage to an individual receiving services, caused by an act of that individual or another, whether or not by accident, and whether or not the cause can be identified, that results in an individual requiring medical or dental treatment by a physician, dentist, physician's assistant, or nurse practitioner, and such treatment is more than first aid.
Part 625 Classifications
Any incident or allegation of abuse that occurs outside the auspices of the agency must be reported to OPWDD within 24 hours. Form OPWDD 150 will be completed for the following events: physical abuse, sexual abuse, emotional abuse, active neglect, passive neglect, self-neglect, financial exploitation, death and “other” (sensitive issues, which do not meet the definitions of another category and are deemed necessary to be brought to the attention of OPWDD).
Physical Abuse
The non-accidental use of force that results in bodily injury, pain, or impairment, including but not limited to, being slapped, burned, cut, bruised, or improperly physically restrained.
Sexual Abuse
Non-consensual sexual contact of any kind, including but not limited to, forcing sexual contact or forcing sex with a third party.
Emotional Abuse
The willful infliction of mental or emotional anguish by threat, humiliation, intimidation, or other abusive conduct, including but not limited to, frightening or isolating an adult.
Active Neglect
The willful failure by the caregiver to fulfill the care-taking functions and responsibilities assumed by the caregiver, including but not limited to, abandonment, willful deprivation of food, water, heat, clean clothing and bedding, eyeglasses or dentures, or health related services.
Passive Neglect
The non-willful failure of a caregiver to fulfill care-taking functions and responsibilities assumed by the caregiver, including but not limited to, abandonment or denial of food or health related services because of inadequate caregiver knowledge, infirmity, or disputing the value of prescribed services.
Self-Neglect
An adult's inability, due to physical and/or mental impairments, to perform tasks essential to caring for oneself, including but not limited to, providing essential food, clothing, shelter, and medical care; obtaining goods and services necessary to maintain physical health, mental health, emotional well-being, and general safety; or managing financial affairs.
AGENCY-ONLY INCIDENTS
Events/occurrences not covered by the categories on OPWDD 147 or 150 and that are reportable internally, will be recorded on the Ontario ARC Therap Services (GER) General Event Reporting. These would include participant confrontations; unusual behavior; and other notable events that the agency deems reportable and significant for tracking and follow up purposes.
Vehicle Accidents
Accidents involving agency or staff vehicles at which time a ticket is issued to a staff member or accidents while transporting persons receiving services where no injuries occur. The Transportation Department requires a MV-104 or accident report to be completed, if it is not completed at the scene of the accident by the responding officer. A motor vehicle accident, by definition is damage to a vehicle due to the movement of a motor vehicle. These will be reported in Therap under General Event Reporting (GER).
Use of Life-Saving Techniques
Application of CPR or use of the AED to assist a person receiving services, staff or volunteer.
Handling of Incidents and Allegations of Abuse
POLICY:
All reportable incidents and allegations of abuse must be documented, investigated and reported according to established agency procedures; must be reviewed by this agency's Incident Review Committee; and must be acted upon in a timely and appropriate manner to bring such matters to closure and to ensure participant safety.
VALUES:
Quality
Quality of Life
PROCEDURE:
Person(s)/Responsibility:
Staff Person on the scene or the first to discover the event: Protects the person involved and takes what action is necessary to stop the incident and ensure the safety and welfare of that person. Reports the event immediately to the Program Supervisor/On-Call.
Program Supervisor/On-Call: Directs the staff person how to respond to the event. Instructs staff to complete the standardized reporting form, and appropriate notifications.
Direct Support Staff: Completes GER and OPW 147 or 150 and Notification Sheet(s) prior to end of shift. Notifies the NYS Justice Center by telephone or email after discussion with supervisor/on-call. Follows supervisory direction on what to do/where to send. Forms are available on Ontario ARC website under button marked “Incident Reporting”.
Program Supervisor: Notifies the Program Director of the incident/allegation as soon as possible.
Program Director: Notifies the Program Director of the incident/allegation as soon as possible. Verifies facts known with staff. Clarifies with staff if situation is reportable ,serious reportable or notable occurrence, or an allegation of abuse. Notifies Director, Quality Assurance.
Program Supervisor: Notifies parents, guardians, correspondents, advocates and Care Coordinators as appropriate, of any reportable or serious reportable incident or allegation of abuse/neglect. Completes Jonathan’s Law notifications as appropriate. If a person receiving services requests a parent, correspondent/advocate not be contacted, a determination will be made whether the person requesting no contact is able to make that decision. If so, it will be honored. Legal guardians of persons receiving services must always be contacted. Completes Willowbrook notifications for class members
Director, Quality Assurance, Program Director (In the absence of the Director, Quality Assurance), Associate Executive Director, Sr. Associate Executive Director: Makes final decision regarding reporting level of the event. Reports all deaths, reportable incidents serious notable occurrences by telephone to OPW’s Incident Management Unit at 518-388-1450 or after hours to 1-888-479-6763. Account of the event must then be sent through IRMA (Incident Reporting Management Application) within 24 hours or the next business day of occurrence. The entire procedure for the initial phase of reporting, recording, and initial investigation and review of any and all incidents should be completed within 24 hours of the incident or its discovery.
Program Supervisor, Program Director:
Verifies with reporting staff the ACCURACY of facts known:
1. Who was involved?
2. What is reported to have occurred?
3. When did the event occur? Or was it discovered?
4. Where did the event occur?
5. Other relevant facts
6. Secures any evidence/documents.
7. Actions taken to protect the person endangered.
Ensures NYS Justice Dept. was notified by staff who witnessed. A number of agency programs, however, operate or sponsor events in the evening and on weekends, when agency offices are closed, including residential services, off-site supported employment contracts, as well as recreational activities, transportation and service coordination.
If an incident is reportable only, up to 48 hours will be permitted for completing an investigation and review and forwarding paperwork. Reporting of events at all sites must meet Part 624 and 625 regulations. In all cases, program supervisory staff should be notified of any and all incidents without delay, in keeping with agency and program specific procedures. These are outlined below.
Ensure all measures have been taken to provide prompt care and to protect persons receiving services from further harm or injury. Determine whether the incident could have been avoided.
Recommend further follow-up:
a. Programmatic or clinical follow-up;
b. Administrative actions;
c. Disciplinary actions.
Director, Quality Assurance: Contacts outside agency (Ontario County Department of Social Services: Child Protective or Adult Protective agencies, law enforcement) to initiate an investigation if it Contacts outside agency (Ontario County Department of Social appears they will be the lead agency, NYS Justice Center for all occurrences under the agency’s auspices
Investigator: For reportable incidents and for serious notable occurrences, asks that an investigator be assigned. Contacts investigator from the agency Investigative Team and informs them of the event. The investigator will generally not be assigned from the same program area or service that is making the initial report. Completes the Investigative Report ()W149)and forwards it to the Director, Quality Assurance within five (5) working days. Discusses the results of the investigation with the Director, Quality Assurance or if unavailable, Program Director, Executive or Sr./ Associate Executive Director. Conducts a more in-depth investigation as necessary.Thoroughly reviews the event and completes an Investigative Report. The report contains:
1) Description of information received on initial notification;
2) Description of investigative procedures;
3) Summary of evidence;
4) Conclusions based on evidence
5) Attaches interviews conducted.
6) Preliminary corrective/preventative recommendations.
7) Ensures follow up for corrective action is implemented and maintained.
Does further investigation as warranted. Investigations of reportable events and serious notable occurrences in program will generally be investigated by a designated agency investigator. Clinical staff may be asked to contribute to an on-going investigation if the situation warrants.
Director, Quality Assurance/Designated QA Staff: Submits information from form OPW147 inton IRMA within 24 hours of observation, occurrence or discovery of a reportable incident or serious notable occurrence, containing as much information as is known at the time.Forwards allegations of abuse with cover letter from the Executive Director, Sr. Associate Executive Director or Associate Executive Director to names subject(s). Sends MHLS (Mental Hygiene Legal Service) a written report of an allegation of abuse occurring in certified programs within (3) three working days. If abuse is possibly criminal, notifies non-emergency dispatcher of event and notifies director that Law Enforcement will respond.
(************ STOPPED HERE, JOSH ****************)
SECTION: 5.9
SUBJECT: Part 624: INCIDENT REPORTING, MANAGEMENT AND REVIEW
TOPIC: Handling of Incidents and Allegations of Abuse, Notifying outside agencies/Law Enforcement
PROCEDURE
Person(s) Responsibility
Sr. Associate Executive Director Faxes copy of 147 to District
Attorney for review.
Director, Quality Assurance Assists staff in calling local Law
Enforcement if evidence of a crime is present, in which person
supported was victimized
SECTION: 5.9.1
SUBJECT: Part 624: INCIDENT REPORTING, MANAGEMENT AND REVIEW
TOPIC: Handling of Incidents and Allegations of Abuse, Outside investigations
POLICY:
All reportable incidents and allegations of abuse must be documented, investigated and reported according to established agency procedures; must be reviewed by this agency's Incident Review Committee; and must be acted upon in a timely and appropriate manner to bring such matters to closure and to ensure participant safety.
The NYS Justice Center or OPWDD Office of Investigations and Internal Affairs (OIIA) as well as Law Enforcement agencies, may conduct investigations into allegations and significant incidents as well. It is the policy of Ontario ARC to cooperate fully with these agencies, lending assistance in gathering information and contacting staff and individuals supported to facilitate a timely investigative process.
PROCEDURE
Person(s) Responsibility
Director, Quality Assurance Will receive information about assignment of investigation through IRMA (Incident Reporting Management Application) data base. Will contact Executive Director; Associate Executive Directors and Program Director to inform them of the agency who will be investigating.
Ensures all documentation and evidence are secured for the investigator, and assists in coordinating meetings and access to other pertinent to event.
Informs Program personnel if individuals supported will be interviewed and needs support in this process.
Program Director/Director , QA Ensures recommendations and corrective actions are implemented as soon as possible.
Incident Review Committee Reviews investigative report for corrective actions/recommendations only. No determination of finding will be challenged if investigation is done by OPWDD or NYS Justice Center.
SECTION: 5.10
SUBJECT: Part 624: INCIDENT REPORTING, MANAGEMENT AND REVIEW
TOPIC: Follow-up Activities Subsequent to an Allegation of Abuse Involving a Staff Member
POLICY:
A complete and thorough investigation of any and all serious reportable incidents and allegations of abuse will be conducted by this agency.
VALUES:
Quality
Quality of Life
PROCEDURE:
Person(s) Responsibility
Program Director
Program Supervisor
Evaluates each situation and requests an assigned investigator or determines event will be investigated by an outside lead agency. Preserves evidence. Causes as little disruption as possible to the daily operation of the program and routine of the person receiving services. Ensures health and safety shall be the primary concern.
Consults with the Executive Director, Senior Associate Executive or Associate Executive Director to select one or more of the following actions to ensure health and safety of the affected individual during an investigation of an allegation of abuse:
1. Removal, reassignment, relocation or suspension of the alleged abuser with or without pay;
2. Increasing the degree of supervision of the alleged abuser;
3. Provision of counseling to the alleged abuser or alleged victim;
4. Provision of increased training to the alleged abuser and staff pertinent to the prevention and remediation of abuse;
5. Investigation or interviewing by other staff, including clinical staff, Behavior Intervention Specialist, LCSW
6. Increasing supervision and support to the affected staff and program participants;
7. Removal or relocation of the allegedly abused individual, consistent with the
SECTION: 5.10
SUBJECT: Part 624: INCIDENT REPORTING, MANAGEMENT AND REVIEW
TOPIC: Follow-up Activities Subsequent to an Allegation of Abuse Involving a Staff Member, continued:
PROCEDURE:
Person(s) Responsibility
Program Director
Program Supervisor
Incident Review Committee
Program Director
Associate Executive Director
Sr. Associate Executive Director
developmental needs of the individual when it is determined that there is a risk to such an individual if he or she remains in program.
Ensures “due process” will occur in the event an allegation of abuse occurs. Informs staff member they have been named in an allegation. Documents the allegation by letter to the alleged abuser.. Discusses follow-up with the Associate Executive Director. Disciplinary actions will be with the approval of the Executive Director, the Sr. Associate Executive Director, or the Associate Executive Directors.
Reviews the initial report, corrective action and results of the investigation within 30 days of occurrence. Communicates the results of the Committee review, substantiated or unsubstantiated to the Program Director, Program Supervisor.
Communicates results to Manager of program. Meets with staff member and if returning to work, arranges reconciliation meeting with individual and subject of investigation. Follows up in writing with preliminary results, pending IRC approval.
Communicates the results of the Incident Review Committee to the alleged abuser and Human Resources in writing.
Takes immediate and appropriate action to exonerate the person against whom the allegation was made when an allegation of abuse is determined to be unfounded.
SECTION: 5.10
SUBJECT: Part 624: INCIDENT REPORTING, MANAGEMENT AND REVIEW
TOPIC: Follow-up Activities Subsequent to an Allegation of Abuse Involving a Staff Member
PROCEDURE: continued
Person(s) Responsibility
Program Director
Associate Executive Director
Sr. Associate Executive Director
Develops and implements within ten (10) days a plan of action when an allegation of child abuse involving a staff member has been accepted and designated as "indicated" by the NYS Child Abuse and Maltreatment Center. The corrective action plan should include the action to be taken with respect to an individual employee or volunteer to assure the continued health and safety of children and action taken to provide for the prevention of future acts of abuse.
In the event of an allegation of sexual abuse
follow agency guidelines on Sexual Interactions which may include:
1. Medical examination of the victim, if allegation severity warrants it;
2. Review of documentation of ability to give consent or determination of the ability to give consent, if needed;
3. Determination if a crime may have been committed;
4. Recommendations for follow-up;
5. Notification to appropriate parties.
In no case will any staff person or other individual directly involved in an incident, or implicated in an allegation of abuse, take part in its investigation.
REFERENCE: PART 633.9
DATE: 7/90
REVISED: 10/95/12/96,5/99, 6/02, 3/04, 4/06, 9/06, 04/07, 9/08,10/11,7/13, 6/19
SECTION: 5.11
SUBJECT: Part 624: INCIDENT REPORTIMG, MANAGEMENT AND REVIEW
TOPIC: NOTIFICATIONS AND REPORTING REQUIREMENTS
POLICY:
As part of this agency's initial procedure for handling of incidents and allegations of abuse, notification to other individuals or outside agencies is made.
VALUES:
Quality
Quality of Life
PROCEDURE:
Person(s) Responsibility
Direct support staff, program supervisor(s), program director(s), Director, Quality Assurance and/or Executive/Sr. Associate Executive Director/Associate Executive Directors(s).
Director, Quality Assurance/Designated QA Staff
Notifies Program Director; Director of Quality Assurance and Sr. Associate Executive Director(s).
Notifies guardian, parent or correspondent/advocate of any agency reportable, reportable incidents, serious notable occurrences or minor notable occurrences not covered under Jonathan’s Law within 24 hours of completion of the initial report unless the alleged abuser is one of these parties, the involved person is a capable adult and objects to notification being made or there is written advice from the guardian or parent that he or she does not want to be notified.
Makes Jonathan’s Law notifications as required. See below.
Utilizes an Incident Notification Sheet and where appropriate Jonathan’s Law Notification and attaches it to a completed form OPW-147.
After notification and approval of Executive Director or his designee, telephones Incident coordinator at Incident Management Unit
(518-388-1450) immediately and enters report of any reportable incident or serious notable occurrence in IRMA database within 24 hours of observation or discovery.
SECTION: 5.11
SUBJECT: Part 624: INCIDENT REPORTING, MANAGEMENTAND REVIEW
TOPIC: Notifications and Reporting Requirements, continued:
PROCEDURE:
Person(s) Responsibility
Director, Quality Assurance/Designated QA Staff
Additional notifications are as follows:
· Mental Hygiene Legal Services (MHLS) is faxed (585 530-3079) a written report of any allegation of abuse occurring under agency auspices within three working days.
· For program participants under 18 years of age, notification by telephone must immediately be made to the NYS Child Abuse and Maltreatment Reporting Center (1-800-342-3720) of occurrences attributable to alleged abuse of a child. If the Justice Center is notified, CPS notification is not necessary.
For any deaths, OPWDD and the NYS Justice Center is to be notified immediately and kept informed of information as obtained. The Death reporting number for NYS Justice Center is 1-855-373-2124.
· OPWDD policy requires agencies to contact the DDRO within two hours for situations which leave OPWDD vulnerable to criticism and/or adverse publicity.
Notifications should be made for events/ situations which involve consumers such as:
-untoward, sudden or unexpected deaths
-assaults and serious injury to
-disappearance of
-criminal acts by
-victimization of
REFERENCE: Part 624.5, Zielnski Memo 4/29/98
DATE: 6/95
REVISED: 10/08,10/11
SECTION: 5.11
SUBJECT: Part 624: INCIDENT REPORTING, MANAGEMENTAND REVIEW
TOPIC: Notifications and Reporting Requirements, continued:
PROCEDURE, continued:
Person(s) Responsibility
Director, Quality Assurance/Designated QA Staff
Or events involving a staff, consultant, volunteer, intern or other such as:
-criminal situations
-potential for public reaction
-potential for media attention
During normal business hours contact is made with the OPW’s Incident Management Unit at 518-388-1450. After hours contact should be made with the DDRO IMU at 1-888-479-6763. The NYS Justice Center can be contacted at 1-855-373- 2122
· All suicides, homicides, accidental deaths or deaths due to suspicious, unusual or unnatural circumstances must be reported immediately by telephone and later in writing to the coroner/medical examiner.
· Law enforcement officials are notified in the case of any reportable incident, serious reportable incident, or allegation of abuse where a crime may have been committed, either by or against an individual receiving services. Any alleged criminal act must be reported to the district attorney or the appropriate law enforcement officials within three working days.
· Any other program, agency, facility or provider of services with which the program participant is associated, is informed by a designated staff person of any reportable incident or allegation of abuse that has resulted in injury or of an event, that may be of concern to another program, or that may impact upon programming or activities at another program.
SECTION: 5.11
SUBJECT: Part 624: INCIDENT REPORTING, MANAGEMENTAND REVIEW
TOPIC: Notifications and Reporting Requirements, continued:
PROCEDURE, continued:
Person: Responsibility:
Program Supervisor, Program Manager, Program Director
REFERENCE: Part 624.4
Date: 5/05
Revised 09/08,10/11,7/13
On no less than an annual basis reviews injuries (per regulation) of unknown origin, corrective action taken and trends noted.
Reports to Director, Quality Assurance.
For WillowBrook Class members all incidents must be reported to :
· WillowBrook Hotline, 718 477 8800 , always leave message describing exactly what is occurring.
· Care Coordinator
· Residence Manager
· Family
· *Required Willowbrook Incident Notification Grid is available on the opwdd.ny.gov website.
SECTION: 5.11.1
SUBJECT: Part 624: INCIDENT REPORTING, MANAGEMENT AND REVIEW
TOPIC: Notifications and Reporting Requirements, continued:
Notifications Specific to Jonathan’s Law
POLICY:
In recognition and compliance with Jonathan’s Law expanded notification to “Qualified Persons” (legal guardian, parent, spouse, adult child) are required for all reportable incidents. Care Coordinators are also entitled to follow up information as requested, to ensure service plans meet the needs of the individuals supported.
VALUES
Integrity
Quality
PROCEDURE:
Person(s):
Responsibility:
Program Manager, Program Supervisor, Program Director
REFERENCE: MHL 33.23, Part 624.3
DATE: MHL 09/08
REVISED: 10/08,10/11,7/13, 6/19
For all reportable incidents and notable occurrences:
Directly contacts “qualified person” (legal guardian, parent, spouse, adult child, advocate) within 24 hours to provide:
1. a description of the event or situation and corrective action/follow-up taken
2. Offer to meet with the Executive Director, Director of Quality Assurance to discuss incident/abuse.
3. Offer to provide written reports of:
Incident/Abuse Report
Investigation upon written request to the Director of Quality Assurance.
4. Notification that a Report of Actions Taken (OPW 148) will be sent in 10 days.
Documents notifications completed on Jonathan’s Law Notification Sheet and attaches to OPW 147 or 150.
SECTION: 5.11.1
SUBJECT: Part 624: INCIDENT REPORTING, MANAGEMENT AND REVIEW
TOPIC: Notifications and Reporting Requirements, continued:
Notifications Specific to Jonathan’s Law, continued:
PROCEDURE:
Person(s): Responsibility:
Program Manager, Program Supervisor,
Program Director
Director, Quality Assurance
Completes Report of Actions Taken (OPW148) and forwards it to Director, Quality
Assurance with 10 days of writing OPW 147 Report.
Mails Report of Actions Taken to Qualified Person within 10 days of date Incident report was written.
Receives requests from “qualified persons” (including Care Coordinators) for copies of OPW 147’s concerning all reportable incidents and notable occurrences. Prepares materials for mailing by removing (redacting) all names and any identifying information except information for the subject of the report (Field #8). Sends information to “Qualified Person.” OPW 147’s must be sent within 10 days of the request.
Receives written requests for copies of investigations of allegations of abuse occurring in program. Redacts all investigations. Sends investigations within 21 days of closure of the alleged abuse case. Closure occurs when the standing committee determines no further investigation is necessary and reaches a conclusion whether the allegation substantiated/unsubstantiated (for abuse/neglect) or founded/unfounded (for significant incidents)
Records all contacts, requests, disclosures in IRMA.
SECTION: 5.11.1
SUBJECT: Part 624: INCIDENT REPORTING, MANAGEMENT AND REVIEW
TOPIC: Notifications and Reporting Requirements, continued:
Notifications Specific to Jonathan’s Law, continued:
PROCEDURE:
Person(s): Responsibility:
Program Supervisor, Program Manager, Program Director
Director, Quality Assurance
REFERENCE: Part 624.8
DATE:5/07
If there is no guardian, parent, spouse or adult child but there is an advocate or correspondent, advocate/ correspondent is notified of the incident/allegation and offered a meeting and must be sent a report of actions taken. Upon request advocates/correspondents must be sent a redacted OPW 147. They are not eligible to receive a copy of the investigation report and other investigation documents.
If the otherwise eligible requestor is the alleged abuser, he or she is not eligible to receive records.
If the participant is a capable adult and objects to the release of records, the otherwise eligible requestor is not eligible to receive records unless the requestor is the legal guardian.
If there is no legal guardian, parent, spouse, child and the person is a “capable adult,” the person receiving services must be contacted within 24 hours, offered a meeting and must receive a Report on Actions Taken (OPW 148) within 10 days of the OPW 147 being written.
Upon written request releases records pertaining to allegations of abuse which occurred or were discovered on or after May 5, 2007.
REVISED: 9/08/7/13, 6/19
SECTION: 5.11.1
SUBJECT: Part 624: INCIDENT REPORTING, MANAGEMENT AND REVIEW
TOPIC: Notifications and Reporting Requirements, continued:
Notifications Specific to Jonathan’s Law, continued:
PROCEDURE:
Person(s): Responsibility:
Director, Quality Assurance
Program Supervisor, Program Manager, Program Director
Redacts names or other information tending to identify people receiving services and employees. For purposes of redaction employees include consultants, contractors, volunteers, family care providers and family care respite, substitute providers and individuals who live in the home of the provider.
Redacts names or other information of anyone who made a report to the Statewide Central Register of Child Abuse and Maltreatment (SCR) or otherwise cooperated in a child abuse/maltreatment investigation.
Notifies Consumer Advisory Board of all incidents/allegations covered under Jonathan’s Law.
· Automatically sends copy of OPW 147 to Ms. Antonia Ferguson, Executive Director of CAB via Fax at (718) 477-8805 or by mail at 1050 Forest Hill Road, Staten Island, NY 10314.
· Sends follow-up Report of Actions Taken (OPW 148) within 10 days.
· Sends minutes of Incident Review Meetings reviewing reportable incidents and serious notable occurrences on a regular and timely basis.
SECTION: 5.11.2
SUBJECT: Part 624: INCIDENT REPORTING, MANAGEMENT AND REVIEW
TOPIC: Notifications and Reporting Requirements,
SECTION: 5.12.1
SUBJECT: Part 624: INCIDENT REPORTING, MANAGEMENT AND REVIEW
TOPIC: Incident Review Committee: Responsibilities
POLICY:
The Incident Review Committee of this agency reviews and monitors all reportable incidents and allegations of abuse, and makes recommendations to the Ontario ARC Board of Directors, Executive Director and other program administrators.
VALUES:
Quality
Quality of Life
PROCEDURE:
Person(s): Responsibility
Incident Review Committee
REFERENCE: Part 624.7
DATE: 05/05
REVISED: 09/08,10/11,7/13, 6/19
· Determines that reportable incidents and allegations of abuse are reported, handled, investigated and documented appropriately and makes recommendations to correct, improve or eliminate inconsistencies.
· Determines that necessary and appropriate corrective, preventive and/or disciplinary action has been taken to protect individuals from further harm and to safeguard against the recurrence of similar incidents or allegations of abuse and to make recommendations to the program administrator to correct, improve or eliminate inconsistencies.
· Determines if further investigation or if additional corrective, preventative and/or disciplinary action is necessary, and if so, makes appropriate recommendations.
· Identifies trends in incidents and/or allegations of abuse and recommends appropriate corrective, preventative and/or supervisory interactions to safeguard against such situations recurring.
· Ascertains and ensures the adequacy of the agency's reporting and review practices, including the monitoring of recommendations for corrective and preventative action.
SECTION: 5.12.1
SUBJECT: Part 624: INCIDENT REPORTING, MANAGEMENT AND REVIEW
TOPIC: Incident Review Committee: Responsibilities (continued:)
PROCEDURE
Person(s) Responsibility
Incident Review Committee
Director, Quality Assurance/Designated QA Staff
· May eliminate or minimize similar reportable incidents and/or abuse situations in the future.
· Makes recommendations to the program administrator on changes in agency/program policy and procedures to improve conditions contributing to the reportable incidents and/or allegation of abuse.
· If Investigation was conducted by OPWDD or NYS Justice Center, IRC
will review OARC actions/notifications and follow up only. All OPW and Justice recommendations must be followed up on within 30 days.
· Documents that all reportable incidents and allegations of abuse have been reviewed by the committee, and that results have been conveyed to appropriate agency administrator.
· Enters Minutes from IRC meetings into IRMA data base for OPWDD review.
· Forwards findings and recommendations to program administrator within two weeks of meeting.
· Reviews and monitors investigation procedures, but does not perform routine investigations.
Makes recommendations, when feasible, to the program administrator .
REFERENCE: 624.7
DATE: 1/92
REVISED: 10/95, 12/96, 5/99, 6/02, 3/04, 9/06, 3/0, 10/08,10/11,7/13, 6/19
SECTION: 5.12.2
SUBJECT: Part 624: INCIDENT REPORTING, MANAGEMENT AND REVIEW
TOPIC: Incident Review Committee: Membership and Organization
POLICY:
The Ontario ARC Incident Review Committee is organized on an agency-wide basis.
VALUES:
Quality
Quality of Life
PROCEDURE:
Members are appointed by the Executive Director and serve for a term of one year. Members may serve consecutive terms, generally up to three years. The committee consists of staff members from all levels of the agency, supervisory, direct support, administrative, clinical, person supported and representatives from the Board of Directors. The committee is chaired by the Director, Quality Assurance. The Quality Assurance/Staff Development Specialist serves as recorder for the committee. The Executive Director, Sr. Executive Director and Associate Executive Director(s) shall not serve on this committee. The full committee reviews all reportable incidents and serious and minor notable occurrences. The committee meets twice a month.
A physician, physician’s assistant or nurse practitioner must serve on the committee or be available for consultation to the committee. A staff nurse will serve on the committee.
A staff Licensed Clinician from OARC will serve on the committee.
An individual receiving services as well as a Direct Support Professional must also serve on the committee.
The Executive Director is consulted when needed.
No committee member may participate in the review of any reportable incident, serious reportable incident or alleged abuse in which he or she was directly involved, in which his or her testimony is incorporated, in which his or her immediate family member was directly involved or which he or she investigated or participated in the investigation. Such person may participate in deliberation regarding appropriate corrective action or preventive action.
REFERENCE: Part 624.7
DATE: 1/92
REVISED: 10/95, 12/96, 5/99, 6/02, 3/04, 9/06, 3/07, 10/08,10/11,7/13, 6/19
SECTION: 5.12.3
SUBJECT: Part 624: INCIDENT REPORTING, MANAGEMENT AND REVIEW
TOPIC: Incident Review Committee: Case Specific Requirements
POLICY:
For review of all serious reportable incidents and allegations of abuse an invited representative from the program or service area where the event occurred or someone familiar with the persons involved attends.
VALUES:
Quality
Quality of Life
PROCEDURE:
The representative attending presents information about the event to the committee and answers questions.
For minor notable occurrences it will not be necessary for a program representative to attend the review. The initial report and follow-up may be submitted in writing. Program supervisors wishing to present at a review may contact the reviewer.
Written minutes are maintained as a record of each Incident Review Committee Meeting and contain committee findings. The Director, Quality Assurance, is responsible for seeing that minutes are kept.
Minutes provide a brief summary of every reportable, serious or minor notable incident and any reviewed, identifying the program participant by name (if involved), the report by number, the incident by date, type and description, and committee discussion, findings or recommendations, if any. Corrective actions initially taken, as well as any to be taken as a result of committee review, shall be incorporated into the minutes.
All information contained and conveyed in committee meetings and incident/abuse reports will be treated as confidential.
Complete sets of minutes are maintained on the agency server in a Shared Drive.. Complete sets of minutes are distributed to the Executive Director, Senior Associate Executive Director, Associate Executive Director, CFO, Sr. Director, Innovative Supports and to all committee members. Minutes of reviews of individual incidents are sent to the program representative assigned to attend Incident Review Meetings. Original Incident reports will be maintained by the Director, Quality Assurance in a confidential manner and in a secure area. Minutes are reported to OPWDD through IRMA data base
Members of the Board of Directors, who sit on the Incident Review Committee, will inform the Board of Directors of committee proceedings.
REFERENCE: Part 624.7
DATE: 1/92
REVISED: 10/95, 12/96, 5/99, 6/02, 5/03, 3/04, 9/06, 3/0, 10/08,10/11,7/13, 6/19
SECTION: 5.12.4
SUBJECT: Part 624: INCIDENT REPORTING, MANAGEMENT AND REVIEW
TOPIC: Incident Review Committee: Annual Trend Report
POLICY:
Ontario ARC will complete all reporting required by the Finger Lakes DDRO and regulation.
VALUES:
Quality
Quality of Life
PROCEDURE:
An annual Trend Report shall be prepared by the Director, Quality Assurance, with the assistance of Program Directors and Program Supervisors and the Incident Review Committee. The report shall identify trends by type, person, site, employee involvement, time, date and circumstance, etc. This report shall be completed by the end of the first quarter of each year. The report shall be reviewed by the Incident Review Committee and forwarded to the Executive Director for review and approval of the Board of Directors. Directors shall also receive a copy of the report. A copy shall be forwarded to the Incident Management Unit by April 15th.
REFERENCE: Part 624.7(b)(4)
DATE: 1/92
REVISED: 10/95, 12/96, 5/99, 6/02, 3/04, 4/06, 9/06,3/07, 10/08,10/11,7/13, 6/19
SECTION: 5.12.5
SUBJECT: Part 624: INCIDENT REPORTING, MANAGEMENT AND REVIEW
TOPIC: Incident Review Committee: Requests for Information
POLICY:
Ontario ARC is committed to forthrightly sharing information regarding reports of incidents and abuse which occur under the auspices of this agency. Ontario ARC is also committed to protecting the privacy of PHI “protected health information” as specified under HIPAA regulations.
VALUES:
Quality
Quality of Life
PROCEDURE:
Person(s) Responsibility
Director, Quality Assurance
Receives and responds to requests for information in accordance with the provisions
of Jonathan’s Law specified above and in accordance with HIPAA policies contained in the Ontario ARC HIPAA Manual.
Sends out redacted reports as requested, maintaining copies.
SECTION: 5.13
SUBJECT: PARTS 624 and 625 : INCIDENT REPORTING AND MANAGEMENT
TOPIC: Discovery of Incidents/Allegations of Abuse (not witnessed)
POLICY:
Ontario ARC is committed to protecting persons who attend our programs or receive support.. Parts 624 NYCRR and NYCRR Part 625 describe the requirements for reporting, documenting, investigating and reviewing events that affect the safety and welfare of people we support. Adherence to these regulations is required of all staff members at all times.
In addition, Social Services law 702 requires that all staff, volunteers, and contractors are “custodians” and mandated to report any allegations of abuse or significant incidents to the New York State Justice Center for the protection of people with Special Needs.
VALUES
Quality
Quality of Life
PROCEDURE:
Person(s) Responsibility
Staff Person Upon discovery of event or allegation of abuse, ensures safety of individual. Reports allegation of account of event to Supervisor immediately.
If program/Agency is certified setting, notifies the New York State Justice Center within 24 hours.
For Ontario ARC programs, notifies program Director and in cooperation, completes necessary Therap GER/Incident Report Form.
Program Supervisor Consults with Program Director and Director, Quality Assurance to determine the location of allegation or reported event.
Staff Person/Supervisor Completes Irregular Situation form and forwards to Director, QA.
Director, Quality Assurance/Designated QA Staff Notifies Sr. Management, OPWDD IMU Coordinator by telephone.
Outside Program/Agency Responds to Justice Center/IMU to investigate and process the incident.
SECTION: 5.13
SUBJECT: PARTS 624 and 625 : INCIDENT REPORTING AND MANAGEMENT
TOPIC: Discovery of Incidents/Allegations of Abuse (not witnessed), con’t
PROCEDURE:
Person(s) Responsibility
Program Director/Supervisor Provides follow-up and referrals for Incidents based on programs that support individual. See hierarchy below:
RESIDENTIAL SERVICES
COMMUNITY RESIDENTIAL HABILITATION
VOCATIONAL SERVICES
FSS OR ISS SERVICES
SECTION: 5.14
SUBJECT: PARTS 624 and 625 : INCIDENT REPORTING AND MANAGEMENT
TOPIC: Corrective Action Plans
POLICY:
Ontario ARC is committed to protecting persons who attend our programs or receive support.. Parts 624 NYCRR and NYCRR Part 625 describe the requirements for reporting, documenting, investigating and reviewing events that affect the safety and welfare of people we support. Adherence to these regulations is required of all staff members at all times.
In addition, Social Services law 702 requires that all staff, volunteers, and contractors are “custodians” and mandated to report any allegations of abuse or significant incidents to the New York State Justice Center for the protection of people with Special Needs.
VALUES
Quality
Quality of Life
PROCEDURE:
Person(s) Responsibility
Executive Director Receives Letter of Determination
(LOD) and forwards to Director, Quality Assurance.
Director, Quality Assurance/Designated Completes Correction Action tab
QA Staff in IRMA. Attaches validation of
correction action completed.
INCIDENT REVIEW COMMITTEE
CURRENT MEMBERS 2019
Lauren Steenburn Director, Quality Assurance, Chairperson
Patricia Lovin Residential Nurse
Jessica Bursley Program Manager
Ashley Hanvey Behavior Support Specialist
Kyle Meath Board of Directors
JoAnn Greco Parent Representative
Val Colombo Supervisor, Transportation,
Kim Villard Employment Specialist
Greg Alexander Custodial Supervisor
Brittany Blair Recorder/ QA/SD Specialist
Carol Guest Manager, Innovative Supports