10a NCAC 27G .0603       incident response requirements for CATEGORY a and b providers

(a)  Category A and B providers shall develop and implement written policies governing their response to level I, II or III incidents.  The policies shall require the provider to respond by:

(1)           attending to the health and safety needs of individuals involved in the incident;

(2)           determining the cause of the incident;

(3)           developing and implementing corrective measures according to provider specified timeframes not to exceed 45 days;

(4)           developing and implementing measures to prevent similar incidents according to provider specified timeframes not to exceed 45 days;

(5)           assigning person(s) to be responsible for implementation of the corrections and preventive measures;

(6)           adhering to confidentiality requirements set forth in G.S. 75, Article 2A, 10A NCAC 26B, 42 CFR Parts 2 and 3 and 45 CFR Parts 160 and 164; and

(7)           maintaining documentation regarding Subparagraphs (a)(1) through (a)(6) of this Rule.

(b)  In addition to the requirements set forth in Paragraph (a) of this Rule, ICF/MR providers shall address incidents as required by the federal regulations in 42 CFR Part 483 Subpart I.

(c)  In addition to the requirements set forth in Paragraph (a) of this Rule, Category A and B providers, excluding ICF/MR providers, shall develop and implement written policies governing their response to a level III incident that occurs while the provider is delivering a billable service or while the client is on the provider's premises.  The policies shall require the provider to respond by:

(1)           immediately securing the client record by:

(A)          obtaining the client record;

(B)          making a photocopy;

(C)          certifying the copy's completeness; and

(D)          transferring the copy to an internal review team;

(2)           convening a meeting of an internal review team within 24 hours of the incident.  The internal review team shall consist of individuals who were not involved in the incident and who were not responsible for the client's direct care or with direct professional oversight of the client's services at the time of the incident.  The internal review team shall complete all of the activities as follows:

(A)          review the copy of the client record to determine the facts and causes of the incident and make recommendations for minimizing the occurrence of future incidents;

(B)          gather other information needed;

(C)          issue written preliminary findings of fact within five working days of the incident.  The preliminary findings of fact shall be sent to the LME in whose catchment area the provider is located and to the LME where the client resides, if different; and

(D)          issue a final written report signed by the owner within three months of the incident.  The final report shall be sent to the LME in whose catchment area the provider is located and to the LME where the client resides, if different.  The final written report shall address the issues identified by the internal review team, shall include all public documents pertinent to the incident, and shall make recommendations for minimizing the occurrence of future incidents. If all documents needed for the report are not available within three months of the incident, the LME may give the provider an extension of up to three months to submit the final report; and

(3)           immediately notifying the following:

(A)          the LME responsible for the catchment area where the services are provided pursuant to Rule .0604;

(B)          the LME where the client resides, if different;

(C)          the provider agency with responsibility for maintaining and updating the client's treatment plan, if different from the reporting provider;

(D)          the Department;

(E)           the client's legal guardian, as applicable; and

(F)           any other authorities required by law.

 

History Note:        Authority G.S. 122C-112.1; 143B-139.1;

Temporary Adoption Eff. July 1, 2003;

Eff. July 1, 2004;

Amended Eff. August 1, 2009.