[32 Pa.B. 2117]
[Continued from previous Web Page] § 6000.471. Certified investigators.
(a) Certified investigators are people who:
(1) Have been trained according to Office of Mental Retardation (OMR) specifications.
(2) Have received a certificate in investigation from OMR.
(b) Providers, counties and OMR shall have certified investigators available to conduct investigations.
(c) To be a certified investigator a person shall:
(1) Be a high school graduate.
(2) Be 21 years of age or older.
(3) Meet the criminal background requirements of the Older Adults Protective Services Act (35 P. S. §§ 10211--10224) and 23 Pa.C.S. §§ 6301--6385 (relating to Child Protective Services Law).
(4) Successfully complete the training.
(d) Training and testing requirements are as follows:
(1) Training and testing will be required for certification as an investigator.
(2) Persons who have taken the course ''Conducting Serious Incident Investigation'' after October 1, 1998, offered by Labor Relations Alternatives, Inc, may apply to take a test to be certified without needing to retake the course.
(3) Only those who pass the test will be certified.
(e) The following apply to certification:
(1) Certification is good for 3 years.
(2) At least once every 3 years certified investigators shall participate in a refresher class to be certified.
(3) Investigators shall have conducted a minimum of three investigations since being certified.
(4) Certification may be withdrawn by OMR for cause.
§ 6000.472. Investigation protocol.
(a) The Office of Mental Retardation (OMR) will establish a protocol for the conduct of investigations.
(b) At a minimum, the investigation protocol will include:
(1) A process for addressing conflict of interest.
(2) Establishing the purpose of the investigation.
(3) Interviewing.
(4) Gathering evidence.
(5) Weighing credibility.
(6) Reporting findings.
(7) Conclusions.
(c) The investigation record shall include:
(1) The incident report.
(2) Evidence.
(3) Witness statements.
(4) The certified investigator's report.
(i) The investigation record shall be secured and separate from the individual's record.
(ii) A summary of the investigator's report shall be entered into the standardized web-based incident report.
(iii) Families and individuals shall be notified of the outcome of all investigations.
§ 6000.473. Data and information analysis.
(a) Provider role. Trend analysis is one of the critical uses of the data, which accumulate when incidents are reported and documented in a database. Trend analyses provide the agency, the county and the Office of Mental Retardation (OMR) with insights into specific issues that cannot be gained from the review of individual reports. As part of an ongoing risk management/quality improvement process, the provider may choose to examine different questions or analyze a specific trend, or both, at regular intervals.
(1) Some suggested areas for trend analysis are as follows which is not an all-inclusive list:
(i) The same things happening to the same individuals over a period of time.
(ii) Different things happening to the same person over time.
(iii) The same things happening across groups over time.
(iv) Involvement of the same staff.
(v) A cluster of incidents that are outside the norm.
(vi) Variations from the norm over time.
(vii) Variables that impact on incidents.
(viii) Impact of place, time, and the like.
(ix) The nature of injury.
(x) High occurrence by type (locked in vehicles, left at site unattended by para transit, and the like).
(xi) Low or no reporting.
(xii) A typical risk or atypical risk.
(xiii) Process analysis/time needed to bring closure.
(xiv) The causes of hospitalization (including psychiatric diagnoses).
(xv) The causes of death (especially those that are sudden and unexpected).
(xvi) Positive findings after allegations.
(xvii) The impact of changes on subsequent rate of events.
(xviii) A comparison of staff vacancy rate with rate/type of incidents.
(xix) A comparison of variables (turnover rate, use of overtime).
(xx) The average number of incidents per person supported (changes over time, locales).
(xxi) The changes in rate of incidents as models of support change.
(xxii) Agency issues (increase in medication errors since, and the like).
(2) The provider review process shall include review of all incident reports and investigation.
(i) Incident reports shall be reviewed individually to determine if provider action has been appropriate and sufficient.
(ii) Incident reports to be reviewed in aggregate to determine if trends may be developing that warrant further intervention for the individual or systemic intervention, beyond what may have been taken in response to the individual incident.
(3) The provider's administrative responses may include the following:
(i) Referral to the Health Care Quality Unit (HCQU).
(ii) Revision of an individual plan.
(iii) Other action necessary to promote the health, safety and rights of individuals served by the provider.
(4) Using system generated data, the provider shall complete and file quarterly reports with the county within 30 days of the end of the calendar quarter that include:
(i) Incidents per month by individual and site.
(ii) Summary comparisons to prior 4 quarters.
(iii) Incidents requiring investigation by individual and site.
(iv) Results of investigations (confirmed, unconfirmed and inconclusive).
(v) Actions to be taken in response to the conclusion/determination.
(vi) Analysis of increases/decreases in numbers and types of incidents from previous quarter and previous year by individual, by location.
(vii) Analysis of individuals with three or more incidents during the reporting period to detect patterns or connections.
(viii) Analysis of significant factors that may influence the data.
(ix) Qualitative analysis of investigations conducted.
(x) Analysis of the implementation of corrective actions during the reporting period.
(xi) Discussion of special areas of concerns identified in the review process.
(b) County role.
(1) The county shall have procedures for the review and analysis of system generated data on all reported incidents. The procedures shall include at least quarterly reviews to determine what trends may be developing.
(2) The county shall report an incident data to OMR at least semiannually on June 1st and December 1st of each year. The report to OMR shall include at a minimum:
(i) Incidents by provider by quarter for the reporting period.
(ii) Summary comparisons of provider data for the past four quarters.
(iii) Incidents requiring investigation by provider.
(iv) Incidents requiring investigation by the county.
(v) Analysis of increases/decreases in numbers and types of incidents from previous reporting period.
(vi) Analysis of individuals with six or more incidents during the reporting period.
(vii) Analysis of significant factors that may influence the data.
(viii) Analysis of the implementation of corrective actions during the reporting period.
(ix) Discussion of special areas of concerns identified in the review process.
(x) A mechanism to communicate the results of its analyses to the providers.
(xi) Discussion of joint actions between the county and the provider to reduce incidents.
(3) Based on trend analysis, counties and HCQUs jointly determine the need for technical assistance.
(c) The HCQU role. The HCQU shall have access to incident data from counties with whom they serve. The HCQU shall review data:
(1) Related to medication errors, emergency room visits, inpatient hospitalizations, suicide attempts deaths and other health related matters.
(2) To determine where trends suggest training, a change in procedures, or where medical supports are needed.
(3) Based on trend analysis, counties and HCQU's jointly determine the need for technical assistance.
(d) The OMR role is as follows:
(1) OMR will review data on all reported incidents at least semiannually to determine what trends may be developing Statewide or by county and take appropriate administrative steps to intervene.
(2) The OMR will issue an annual report reviewing Statewide incident trends.
§ 6000.474. Families.
The Office of Mental Retardation (OMR) joins families in concern about the health and safety of their relatives who receive supports and services through its licensed and funded programs. This subchapter specifies the process for providers, counties and the OMR to report and investigate incidents that jeopardize the health and safety of individuals receiving services. In addition to the requirements placed on those providing and overseeing services, the OMR also relies on families to report incidents that may affect the family member's health and safety.
(1) Notification to families. Family members of individuals who receive services outside the family home, have a right to receive timely, accurate and complete information regarding their relative's health and safety. Unless otherwise indicated by family members receiving services outside the family home:
(i) Family members shall be notified of the reportable incidents.
(ii) Family members shall be notified with 24 hours of occurrence or when they are discovered.
(iii) Family members shall be notified of the outcome of any investigation when it is complete.
(2) Notification of incidents by families.
(i) If a family member observes or suspects abuse, neglect or inappropriate conduct, whether services are provided out of the home or in the home, the family member should contact the county supports coordinator and may also contact OMR directly at 1-888-565-9435.
(ii) In the event of a death, the family is to notify the supports coordinator. The supports coordinator assumes the role of the point person as described in § 6000.467 (relating to reporting roles).
(3) When services are provided in the family's home.
(i) An increasing number of individuals are supported in their own homes or the homes of their families. When services are provided in the home of an individual or his family:
(A) Provider employees or their contract agents shall report incidents involving the individual receiving services that occur when they are present in the home.
(B) Providers or their contract agents shall report possible abuse of which they become aware regardless of whether they are present at the time or whether it involves a paid caregiver.
(C) If the family observes inappropriate conduct, it should contact the upports coordinator to initiate an incident report or they may also contact OMR directly at 1-888-565-9435.
(D) When a family reports questionable conduct that may constitute abuse, an investigation shall be conducted by a certified investigator.
(E) If a provider staff is present when an incident occurs or becomes aware of abuse, the provider shall report the incident in Home and Community Based Services Information System (HCSIS). The provider is responsible for investigating the situations that directly involve its staff or volunteers.
(F) If provider staff observes abuse that does not involve the provider staff, the provider should report the situation to the supports coordinator who will assume the role of point person and file an incident report in HCSIS. The supports coordinator in conjunction with the county Incident Manager will determine if a certified investigator will investigate or a referral to Childline or law enforcement, or both, will be made. The county certified investigator will document in HCSIS either the summary of the investigator's investigation or that of Childline/law enforcement.
(ii) Families are encouraged to cooperate to assure fairness and accuracy of the report.
(4) When the family is the provider of service.
(i) When a family member is the provider, that is, is identified in the individual plan as the provider and is receiving remuneration, incidents needing investigation by the provider (see § 6000.465 (relating to reportable incidents)) shall be reported to the supports coordinator who will initiate an incident report.
(ii) If that the family provider is the target of an investigation, the family provider may request that the county assign a certified investigator, unrelated to the target, that is also a family member of a person with mental retardation.
(5) When individuals and families purchase community services. Families and individuals may purchase services from community organizations and individual people who are not licensed or otherwise regulated by the OMR, who have no contractual relationship with the county and who are therefore not covered by this subchapter.
(i) Entities such as YM/WCAs, community recreational programs, adult education programs and clubs are included.
(ii) If individuals or family members become aware of abuse or neglect involving these entities or organizations, a report of the incident shall be made to their supports coordinator or OMR at 1-888-565-9435.
(6) Incidents involving children 18 and under. Any act of abuse or neglect which constitutes criminal conduct shall be reported under 23 Pa.C.S. §§ 6301--6385 (relating to Child Protective Services Law), if applicable, and to local law enforcement. Families may contact their support coordinator for assistance in making the reports.
(7) Reporting deaths. Death of a family member can be an emotionally trying time and the sympathies of the people who are responsible to administer supports and services shall be extended to family members at those times. Family members shall notify the supports coordinator of the death of an individual receiving services as soon as possible.
[Pa.B. Doc. No. 02-744. Filed for public inspection April 26, 2002, 9:00 a.m.]
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