§ 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.
Authority 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)).
Source The provisions of this § 2390.18 adopted May 9, 1986, effective August 8, 1986, 16 Pa.B. 1693; amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177; amended October 4, 2019, effective in 120 days, 49 Pa.B. 5777. Immediately preceding text appears at serial page (381394).
Cross References This section cited in 55 Pa. Code § 2390.196 (relating to medication errors).
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