La. Admin. Code tit. 48 § I-1305

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-1305 - Where to Report Incidents

A. Incidents which must be Reported to the Gary W. Project Office. All incidents of:

1. physical abuse, sexual abuse, seclusion, unauthorized or inappropriate use of restraint, and neglect must be reported to the Gary W. Project Office;

2. any injury to a class member, no matter what the cause, which requires more than first aid (for example, any injury which requires: treatment by a physician, hospitalization, stitches, or more than one visit by a health care provider); or

3. elopement of class members whose absence constitutes a recognized danger to the possible well being of that class member or others would be reported immediately to the project office. For class members not in this category, the decision for reporting the absence shall be based on reasoned judgment, by taking into consideration the client's habits, deficits, mental status, capabilities, health problems, and similar considerations, but shall in no instance exceed 72 hours.

4. the occurrence of any of the above incidents shall be reported by the project office to the Quality Assurance Monitoring Group/Independent Monitoring Unit within 24 hours of their receipt of the report.

B. Incidents which must be Reported to the Designated Representative of the Local Oversight Committee

1. All incidents involving psychological abuse, all elopements in excess of 24 hours, and all unusual occurrences must be reported to the Local Oversight Committee, except those noted above in Paragraphs A.2-3. In case of reasonable doubt about whether an incident should be reported to the Gary W. Project Office or to the local oversight committee, the incident must be reported to the Gary W. Project Office with a comment or notation that the person who is reporting the incident is in doubt as to whom the incident should be reported.

C. Flow and When to Report an Incident

1. Each facility shall at all times have two designated representatives who are available to receive incident reports from employees at any time.

2. Every employee of a facility must report any incident both in writing and by telephone to either the Gary W. Project Office or to the designated representative in accordance with Subsections A-B of this Section of this policy whenever the employee becomes aware of or has reason to believe that an incident has occurred.

3. The written report shall be filed on a Standard Incident Report Form and must be filed (or mailed) immediately, but in no event later than 24 hours following the incident. A copy of the incident report must also be sent to the class member's case-manager. The telephone report, containing all available information regarding the incident, must be made immediately, but in no event later than 12 hours following the incident.

4. Any employee who reports an incident to the Gary W. Project Office shall also report the incident to a designated representative and the facility administrator. If the employee believes that the designated representatives are involved in the incident, the employee shall report the incident to the Gary W. Project Office and to the facility administrator, his or her designee, or some other member of management of the facility and note his or her belief regarding the involvement of the designated representative.

5. The designated representative shall immediately review the incident report to ensure that it has been properly reported in accordance with this recommendation. If further reporting is required, the designated representative shall immediately (i.e. not later than 24 hours after receiving the employee's report) forward the report to the Gary W. Project Office and/or the casemanager. In addition, the designated representative shall send a copy of each incident report to the local oversight committee.

6. In the event that a verbal or telephone report of an incident involving a community class member is received by DHH from any individual, the DHH employee who receives the report will immediately communicate the information by telephone to the Gary W. Project Office. The project office will immediately communicate the report by telephone to the class member's casemanager. The casemanager will take appropriate action to prepare and file a standard incident report form immediately, but in no event later than 24 hours from the time the casemanager was notified by the project office of the incident.

D. Casemanager

1. Whenever a casemanager has reason to believe that an incident has occurred, he/she shall immediately determine whether an incident report has been filed under these rules. If an incident report has not been filed, the casemanager shall immediately report both the suspected incident and the failure of the facility to file an incident report to the Gary W. Project Office.

E. Special Rules for Small Facilities

1. Any person associated with a small facility who has responsibility to provide care and/or service to one or more Gary W. classmembers must report any incident both in writing and by telephone to the Gary W. Project Office whenever that person becomes aware of or has reason to believe that an incident has occurred.

2. The written report shall be filed on a standard incident report form and must be filed immediately, but in no event later than 24 hours following the incident. A copy of the incident report must also be sent to the class member's casemanager. The telephone report, containing all available information regarding the incident, must be made immediately, but in no event later than 24 hours following the incident.

3. Responsibility for investigation of allegations of incidents in small facilities shall be as follows: The state will investigate all incidents of abuse and neglect and the following unusual occurrences: restraint, medication error, injuries whose cause cannot be determined, and elopement of the kind described in A.3 of this Section. For all other incidents, the Gary W. Project office may, in its discretion, request the responsible individual to conduct the investigation, but the state must conduct the investigation if:

a. there is any reason to believe that the responsible individual or any member of his/her family or staff were involved in the incident; and

b. this is a multiple incident.

4. Investigation of all incidents in small facilities shall commence within 12 hours of the receipt of the telephone report of the incident. During this 12-hour period, the investigator shall visit the facility and meet with the class member. The investigation shall be completed as soon as possible but, in any event, no later than 30 days after it was started.

5. The provision of this policy contained in Subsections A-C of this Section and §1307 and any references to the local oversight committee shall not apply to small facilities.

6. All other provisions of this policy shall apply to small facilities.

F. Special Rules for Community Class Members. The following rules govern investigations of incidents involving community class members:

1. The OHD investigative unit will investigate all incidents of abuse and neglect and the following unusual occurrences: restraint and injuries whose cause cannot be determined. For all other incidents, the casemanager shall conduct the investigation.

2. Investigation of all incidents involving community class members shall commence within 12 hours of the receipt by the Gary W. Project Office of a telephone report of an incident. During the 12-hour period, the investigator shall visit with the class member. The investigation shall be completed as soon as possible but, in any event, no later than 30 days after it was started.

3. The provision of this policy contained in Subsections A-C of this Section and §1307 and any references to the local oversight committee shall not apply to community class members.

4. All other provisions of this policy shall apply in small facilities.

La. Admin. Code tit. 48, § I-1305

Promulgated by the Department of Health and Human Resources, Office of the Secretary, LR 13:246 (April, 1987), amended LR 13:299 (May, 1987), amended LR 14:536 (August 1988).

AUTHORITY NOTE: Promulgated in accordance with Gary W., et al., vs. State of Louisiana, Civil Action 74-2412.