D.C. Mun. Regs. tit. 29, r. 4254

Current through Register Vol. 71, No. 44, November 1, 2024

Rule 4254 - INCIDENTS AND COMPLAINTS

4254.1

Providers are required to report critical incidents that may threaten the beneficiary's health or welfare for review and follow- up by DHCF and/or other designated agencies. The critical incidents consist of the following categories:

(a) Serious reportable incidents (SRI); and

(b) Reportable incidents (RI).

4254.2

SRI are those incidents which due to their significance or severity to the beneficiary require immediate response, notification, internal review and investigation by the provider agency and DHCF.

4254.3

RI are significant events or situations that involve harm or risk to the beneficiary.

4254.4

SRI include, but are not limited to:

(a) Unexpected death due to abuse, negligence, or accident;

(b) Abuse;

(c) Neglect or abandonment;

(d) Exploitation;

(e) Theft of consumer personal property;

(f) Serious physical injury;

(g) Inappropriate or unauthorized use of restraints;

(h) Suicide threats;

(i) Serious medication errors; and

(j) Suicide attempts or serious fire incidents that could have resulted in serious bodily harm or death.

4254.5

RI include, but are not limited to:

(a) Medication errors;

(b) Hospitalization;

(c) Injuries;

(d) Emergency Room visits;

(e) Fire Occurrences involving property damage;

(f) Police Incidents;

(g) A temporary relocation due to emergencies; and

(h) Other events or situations that involve harm or risk of harm to beneficiaries.

4254.6

Each service provider shall develop internal policies and procedures regarding incident reporting and investigation that meets the following minimum criteria:

(a) Notifying DHCF staff via the electronic management system within twenty four (24) hours or the next business day of an occurrence of an SRI or RI;

(b) Documenting of the incident on an established incident report form in the electronic management system;

(c) Completing of an internal investigation within five (5) business days of the SRI or RI's occurrence; and

(d) Reporting for all SRIs involving death, neglect, abuse, and theft of consumer personal property occurring at a beneficiary's natural home to Adult Protective Services and DHCF.

4254.7

All providers shall establish an internal process for tracking information related to the occurrence of incidents and the outcome of investigations to predict and mitigate recurring incidents.

4254.8

Each provider shall maintain a copy of all incidents and keep them on file for a minimum period of ten (10) years, or until any DHCF, law enforcement, or Adult Protective Services' investigation of an incident has concluded, whichever is longer.

4254.9

A complaint is an expression of dissatisfaction or a formal charge of wrong-doing brought against an EPD Waiver Provider or individual providing services. Complaints include but are not limited to the following:

(a) Denials or reductions of service;

(b) Delays in the process resulting in a denial of eligibility;

(c) Provider tardiness or poor quality of care;

(d) Restriction of individual rights;

(e) Lack of choice of service provider;

(f) Obstructing the beneficiary's choice of preferred service provider when available; and

(g) Violations of privacy and confidentiality policies as outlined under a providers' privacy plan as required in accordance with the requirements set forth in Section 4207.

4254.10

Each service provider shall develop internal policies and procedures regarding complaint documentation and a review process that meets the following minimum criteria:

(a) An explanation of types of complaints that shall be addressed;

(b) The identification of a designated complaint officer who shall manage the complaint process;

(c) The timelines for addressing the compla ints which shall specify the following:

(1) All complaints that pose an immediate risk to the beneficiary shall be addressed by the complaints officer within twenty four (24) hours or next business day of the receipt of the complaint;

(2) Complaints pertaining to Medicaid eligibility determination and denial or reduction of service shall be addressed by the complaints officer within five to seven (5 - 7) bus iness days;

(3) All other complaints will be addressed by the complaints officer within ten (10) business days;

(d) Procedures verifying that all complaints are resolved within thirty (30) business days of the reporting of the complaint to the designated complaint officer; and

(e) The procedures that are used to resolve the complaints.

4254.11

All provider entities shall establish an internal process for tracking and trending information related to the occurrence of complaints and the outcome of investigations.

4254.12

Each provider shall maintain a copy of all complaints on file for a minimum period of ten (10) years.

4254.13

DHCF shall issue a transmittal notifying providers to log complaints into the EPD Waiver Complaint Database upon its operation.

D.C. Mun. Regs. tit. 29, r. 4254

Final Rulemaking published at 64 DCR 6787 (7/21/2017)