Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart A - Statements of Policy › Chapter 6000 - STATEMENTS OF POLICY › Subchapter R - PROCEDURES FOR SURROGATE HEALTH CARE DECISION MAKING › STATUTES › Appendix E - INCIDENT MANAGEMENT COMPONENTS

Current through Register Vol. 54, No. 28, July 13, 2024
PROVIDERS/ENTITIES ARE
						  TO:
* Promote the health, safety, rights and enhance the
						  dignity of individuals receiving services.
* Develop provider-specific policy/procedures for
						  incident management.
* Ensure that staff and others associated with the
						  individual have proper orientation and training to respond to, report and
						  prevent incidents.
* Provide ongoing training to individuals and families
						  on the recognition of abuse and neglect.
* Ensure when incidents occur that affect a person's
						  health, safety or rights, that the people who are present:
- Take prompt action to protect the person's health,
						  safety and rights. This includes separation of the target when the individual's
						  health and safety are jeopardized. This separation shall continue until an
						  investigation is completed. In addition, the target shall not be permitted to
						  work directly with any other service recipient during the investigation
						  process. When the target is another individual receiving supports or services,
						  and complete separation is not possible, the provider shall institute
						  additional protections.
- Notify the responsible person designated in provider
						  policy.
* Assign trained individual(s) Point Person(s) to whom
						  incidents are reported when they occur and who will make certain that all
						  immediate steps to assure health and safety have been implemented and follow
						  the incident through closure.
* Contact appropriate law enforcement agencies when
						  there is suspicion that a crime has occurred.
* Comply with all applicable laws, regulations and
						  policies.
* Conduct certified investigations.
* Analyze the quality of investigations.
* Respond to concerns from individuals/family about the
						  reporting and investigation processes.
* Inform the family of the incident unless otherwise
						  indicated in the individual's plan.
* Notify the family of the findings of any
						  investigation unless otherwise indicated in the individual's plan.
* Maintain an investigation file within the
						  agency.
* Create an incident management process which:
- Designates an individual with overall responsibility
						  for incident management.
- Considers possible immediate and long-term effects to
						  the individual resulting from an incident or multiple incidents.
- Uses trend analyses to identify systemic
						  issues.
- Analyzes and shares information with relevant staff,
						  including direct care staff.
- Periodically assesses the effectiveness of the
						  incident management process.
- Monitors quality and responsiveness of all ancillary
						  services (such as health, therapies, etc.) and acts to change vendors or
						  subcontractors, or assists the individual to file available grievances or
						  appeals procedures to secure appropriate services.
COUNTIES ARE TO:
* Promote the health, safety, rights and dignity of
						  individuals receiving services.
* Develop county policies and procedures necessary to
						  implement this bulletin.
* Have an administrative structure sufficient to meet
						  mandates of this bulletin:
- Designate an individual with overall responsibility
						  for incident management.
- Train staff in incident management procedures.
- Assure that supports coordinators have proper
						  orientation and training to respond to, document and prevent incidents.
- Support providers with appropriate training and
						  resources to meet the mandates of the bulletin.
* Provide ongoing training to individuals, families,
						  guardians, and advocates regarding their rights, roles and responsibilities
						  that are outlined in this bulletin.
* Provide training to individuals and families on the
						  recognition of abuse and neglect.
* Have the Incident Management Processes in this
						  bulletin referenced in county/provider contracts.
* Maintain an investigation file within the
						  county.
* Create an incident management process which:
- Assures accuracy of incident reports.
- Reviews and closes all provider generated
						  incidents.
- Reviews and analyzes data.
- Identifies and implements individual and systemic
						  changes based on data analysis.
- Analyzes and shares information with relevant
						  staff.
- Regularly reviews trend and occurrence data compiled
						  by providers.
- Assesses provider's incident management and
						  investigative processes.
- Assures provider compliance with plans of correction
						  resulting from incidents and investigations.
* Conduct certified investigations.
* Analyze the quality of investigations.
* Respond to concerns from individuals/family about the
						  reporting and investigation processes.
* In collaboration with the individual's planning team,
						  revise the individual's plan as needed in response to issues identified through
						  the incident management process.
* Comply with all applicable laws, regulations and
						  policies.
* Coordinate with other agencies as necessary.
* In those instances where the county is the initial
						  reporter of the incident, the county will assume the responsibility of the
						  point person.
THE OFFICE OF MENTAL RETARDATION IS
						  TO:
* Promote the health, safety, rights and dignity of
						  individuals receiving services.
* Create an incident management review process
						  which:
- Maintains the statewide data system.
- Analyzes data for statewide trends and issues.
- Identifies issues and initiates systemic changes and
						  provides periodic feedback.
- Evaluates county and provider reports and analysis of
						  trends.
* Monitor implementation of this bulletin.
* Support providers and counties with appropriate
						  training to meet the mandate of the bulletin.
* Certify investigators.
* Provide support and technical assistance to counties
						  to implement the incident reporting system.
* Conduct certified investigations.
* Analyze the quality of investigations.
* Respond to concerns from individuals/families about
						  the reporting and investigation processes.
* Review and revise this bulletin as needed.
* Ensure compliance with all applicable laws,
						  regulations and policies.
* Coordinate with other agencies as
						  necessary.
This appendix cited in 55 Pa. Code §
														6000.902 (relating to
							 purpose).