SUBJECT: INCIDENT REPORTING AND INVESTIGATION POLICY (NON-OPWDD)

SUBJECT: INCIDENT REPORTING AND INVESTIGATION POLICY (NON-OPWDD) 1.0 POLICY Classification: QI 2.0 PURPOSE Procedure#: ADM-9125-002 3.0 APPLICABILITY Effective Date: July 2013 4.0 INCIDENT DEFINITIONS Revised Date: 6/15/2016 5.0 GENERAL INFORMATION 6.0 PROCEDURE There are no divisional policies regarding this subject. 1.0 POLICY: 1.1 The Center for Disability Services (CFDS) is committed to ensure the health and safety of the individuals it serves and to thoroughly and immediately investigate any reportable or serious individual incidents. The CFDS s Incident Management Process includes organizational efforts and systems to prevent, identify, investigate, review, and respond to allegations and incidents of abuse, neglect and other untoward events, which may affect individual quality of care. 2.0 PURPOSE: 2.1 The purpose for reporting, investigating, reviewing, correcting, and/or monitoring certain events or situations are to enhance the quality of care provided to persons with developmental disabilities, to protect them (to the extent possible) from harm, and to ensure that such persons are free from abuse and neglect. 2.2 A primary function of the reporting of certain events or situations is to enable a governing body, executives, administrators, and supervisors to become aware of problems, to take corrective measures, and to minimize the potential for recurrence of the same or similar events or situations. The prompt reporting of these events and situations can ensure that immediate steps are taken to protect persons receiving services from being exposed to the same or similar risk. 2.3 The reporting of certain events or situations in an orderly and uniform manner facilitates identification of trends, whether within a facility or class of facilities, by one or more agencies, or on a statewide basis, which ultimately allows for the development and implementation of preventive strategies. 3.0 APPLICABILITY: 3.1 This policy applies to all fact-finding investigations involving individual incidents in non-opwdd programs. 3.2 This policy applies to all employees at the CFDS and its affiliated companies, including volunteers, visitors, family care providers, contracted employees, consultants, and interns. 4.0 INCIDENT DEFINITIONS: 4.1 Agency Events These events or situations need to be recorded on an Agency Events Form and are investigated, reviewed and monitored for trends to allow for 1

the development and implementation of preventative strategies. Program Management, in conjunction with clinical team/staff, reviews events at least quarterly in Program Incident Review Committee. It should be noted that some incidents may rise to the level of a reportable incident resulting in an independent investigation through the Quality 5.0 GENERAL INFORMATION: 5.1 In accordance with all applicable laws and regulations governing individual incidents, an investigatory process has been established for the systematic collection of information to describe and/or explain an event. 5.2 All investigations will be conducted under the direction of the Quality 5.3 Investigations will vary in their scope and intensity depending upon the circumstances surrounding the event under investigation. 5.4 The agency will take any and all appropriate actions immediately after the incident occurs or is identified to first and foremost safeguard the individual(s). This may include the suspension of employees pending the outcome of the incident investigation. The suspension of employees is used as a protective measure for the individual and the employee in question as well. 5.5 Investigations will only be done by designated staff that have received training in investigative techniques. 5.6 Investigator(s) will be assigned to a particular investigation by the Quality Every effort will be made to assign an investigator who is independent from the oversight or management of the program. 5.7 Investigator(s) will be responsible for gathering evidence related to the incident including, as appropriate, interviewing and taking statements from employees, individuals, etc. 5.8 Investigations are time sensitive and require the complete and immediate cooperation of all employees. Failure to do so may result in disciplinary action up to and including termination. The investigator(s) will make every effort to complete the investigation interviews within (10) working days. 5.9 The information obtained in the course of an individual incident investigation is confidential and will be made available only to the investigator(s), Director of Quality Improvement, Program Management, and all regulatory agencies as required. 2

5.10 Everyone involved in the investigation will make all reasonable attempts to ensure that employees and individuals are maintaining confidentiality during the investigatory process. 5.11 If at any time during the course of the investigation it appears that criminal activity may have occurred, the agency is required by law to notify the appropriate law enforcement agency. A representative of the Quality Improvement Department or designee should effectuate this notification. If law enforcement becomes involved, the agency is required to cooperate fully with their investigation and furnish them with such information as may be reasonably requested except with respect to confidential information regarding an individual which may only be released pursuant to Mental Hygiene Law. 5.12 Any questions regarding the release of information and/or appropriateness of disclosure to law enforcement should be referred to a Director of Quality Improvement or agency counsel. 5.13 Competent investigations protect individuals, innocent employees and the agency. In order for the investigatory process to function effectively it is necessary that all employees cooperate to the fullest of their ability at all times in this process. This necessitates that the employees understand the importance of their participation and cooperation. Employees need to appreciate and understand that they are not taking punitive measures against fellow employees when they report an incident of alleged abuse or neglect. It is their duty and responsibility to report any incidents or circumstances that they are aware of which may be placing the individuals that we serve at risk. (see Mandated Reporter Policy) 5.14 Individual incident and investigation documentation are business/administrative records, not part of individual records. 3

6.0 PROCEDURE: Program Manager/Supervisor 6.1 Ø Program s first responsibility is to ensure that Individual s immediate needs are met and to safeguard the situation. Supervisor reports incident to the Quality Ø Ensures that appropriate actions were taken. Ø Ensures that all required notifications were made. Ø Assists with arranging investigation interviews (with individuals and employees). Ø Provides any needed documentation or access to records to investigators. Ø Attempts to ensure that employee and individuals are maintaining confidentiality throughout this process. Ø Upon receiving approval from the Director of Quality Improvement or the investigator(s), follows up with staff/individuals regarding outcome of investigation and any recommendations which may result. Quality Improvement 6.2 Ø Assigns investigator(s) and ensures appropriate notifications have been made. Ø Formulates appropriate investigatory questions/issues. Ø Commences the investigation immediately. Ø Ensures that all physical evidence is preserved/secured by the program. Ø Maintains communication with the Program Director as to the overall status of the investigation. Ø Ensures documentation of all interview statements, medical reports, etc. Ø Completes the investigation in its entirety within five business days, barring unforeseen circumstances. Ø Follows up with Program Director as to the outcome of the incident investigation. All completed incident investigation information will be maintained by the Quality Improvement Department for a minimum of 7 years from the date of the incident. Ø Completes the final investigation report and makes draft recommendations and submits to Incident Review Committee for review. ADM-9125-002 Individual Incident Investigation 4

Program Director 6.3 Ø Assists and cooperates with the investigator(s) at all stages including facilitating employees availability for interviews, providing access to records or other relevant information, etc. Ø Responsible for preserving/securing all physical evidence. Employee 6.4 Ø Must cooperate with and participate fully in all stages of investigation process as needed. ADM-9125-002 5