N.Y. Comp. Codes R. & Regs. tit. 14 § 624.6

Current through Register Vol. 46, No. 51, December 18, 2024

Section 624.6 - Notifications

(a) For a report of abuse or neglect involving a person who resides in a facility certified or operated by OPWDD, the agency under whose auspices the event occurred and/or that is responsible for the person must send the written initial incident/occurrence report to the Mental Hygiene Legal Service (MHLS; see glossary, section 624.20) within three working days of occurrence or discovery. The responsible agency or program must also inform MHLS of the results of the investigation.

(b) For reports of abuse or neglect that occur when a person receiving services is under the auspices of a residential facility operated by OPWDD, a family care home sponsored by OPWDD, or a certified day program operated by OPWDD, OPWDD must send the written initial incident report to the appropriate board of visitors within three working days of occurrence or discovery. OPWDD must also inform the board of visitors of the results of the investigation.

(c) All suicides, homicides, accidental deaths, or deaths due to suspicious, unusual, or unnatural circumstances must be reported immediately by telephone, and later in writing, to the coroner/ medical examiner. In New York City, the police must also be notified.

(d) Reporting to law enforcement.

(1) An appropriate law enforcement official must be contacted immediately in the event that an emergency response by law enforcement is needed.

(2) Agencies must report to an appropriate law enforcement official anytime a crime may have been committed against an individual by a custodian. This is in addition to reporting to the Justice Center when the event or situation is a reportable incident (if the services are certified or operated by OPWDD).

(i) The report to the appropriate law enforcement official must be made as soon as practicable, but in no event later than 24 hours after occurrence or discovery.

(ii) Information about the report to the appropriate law enforcement official must be entered into IRMA within 24 hours of the report being made.

(e) In a case where a subject (see glossary, section 624.20) of a report of abuse or neglect in a program certified or operated by OPWDD resigns from his or her position or is terminated while under investigation, the agency shall promptly report such resignation or termination to the Justice Center.

(f) For all reportable incidents and notable occurrences:

(1) The agency must provide telephone notice to one of the following: a person's guardian, parent, spouse, adult child, or adult sibling.

(2)

(i) if the guardian, parent, spouse, adult child, or adult sibling is the alleged abuser;

(ii) if there is written advice from the guardian, parent, spouse, adult child, or adult sibling that he or she objects to receiving such notification. The notice must then be provided to another party who is a guardian, parent, spouse, adult child, or adult sibling if one exists; or

(iii) if the person receiving services is a capable adult who objects to such notification being made. If the capable adult objects to notification of all parties (guardian, parent, spouse, adult child, or adult sibling), the capable adult must be provided the notice described in this subdivision.

(3) The telephone notice must be provided as soon as reasonably possible, but no later than 24 hours after completion of the written initial incident/occurrence report (for minor notable occurrences) or entry of initial information in IRMA by the agency.

(4) The telephone notice must include:

(i) a description of the event or situation and a description of initial actions taken to address the incident or occurrence, if any;

(ii) an offer to meet with the chief executive officer (or designee) to further discuss the incident or occurrence; and

(iii) for reports of abuse and neglect, an offer to provide information on the status and/or finding of the report. Requested information shall be provided verbally or in writing, unless the person is a capable adult and objects to the provision of this information. In providing such information, the agency must protect the privacy rights of other parties.

(5) Methods of notification.

(i) The complete telephone notice may include more than one call, if the initial call includes a description of the event or situation and is within the required period of time or is attempted within the required period of time. Follow-up calls with the additional required information must be made within a reasonable timeframe after the initial call.

(ii) Notice may be provided in person rather than by telephone.

(iii) Notice may be provided by other methods at the request of the party receiving the notice.

(6) If the person does not have a guardian, parent, spouse, adult child, or adult sibling, or if such parties are not reasonably available, or if there is written advice that such parties do not want to be notified; the agency must provide notice to the following parties in the manner (and subject to the same limitations) specified in this subdivision:

(i) the person receiving services, if the person is a capable adult; and

(ii) the person's advocate or correspondent (if one exists).

(7) Requests for the initial incident/occurrence report.

(i) Process for requests.

(a) Requests may be made for a copy of the initial incident/occurrence report by the person receiving services (or who formerly received services), guardian, parent(s), or correspondent/advocate.

(b) Such request must be in writing. However, at the discretion of the agency, a documented verbal request may be accepted in lieu of a written request.

(c) If the person is a capable adult and objects to the provision of the initial incident/occurrence report, such report must not be provided to otherwise eligible requestors.

(d) If an otherwise eligible requestor is the alleged abuser, the written initial incident/occurrence report must not be provided to that requestor.

(ii) Redaction.

(a) The copy of the report must incorporate redaction of the names of employees who are involved in the incident or occurrence or the investigation or who are interviewed as a part of the investigation; persons receiving services (or who formerly received services); and any information tending to identify such employees or persons. Redaction may be waived if the employee or person authorizes disclosure, unless redaction of the specific information is necessary because it tends to identify another employee or person who has not authorized disclosure or for another reason specified in this subparagraph.

(b) In addition, if the report identifies a particular party as having made a child abuse or maltreatment report to the Statewide Central Register of Child Abuse and Maltreatment (SCR), contacted the SCR, or otherwise cooperated in a child abuse/maltreatment investigation, that name as well as any information tending to identify the party must be redacted.

(iii) The copy of the initial incident/occurrence report must be provided to an eligible requestor as soon as reasonable, but in no event more than 10 days after the request is made.

(iv) The copy of the initial incident/occurrence report must be accompanied by a statement that all contents are preliminary and have not been substantiated.

(8) Report on actions taken.

(i) The agency must provide a report on initial actions taken to address the incident or notable occurrence. Such report must include:

(a) any immediate steps taken in response to the incident or occurrence to safeguard the health or safety of the person receiving services; and

(b) a general description of any initial medical or dental treatment or counseling provided to the person in response to the incident or occurrence.

(ii) The agency must provide the report on actions taken to any party specified in paragraph (1) or (6) of this subdivision who received the notification.

(iii) The report must be provided within 10 days of the completion of the initial incident/occurrence report (for minor notable occurrences) or entry of initial information in IRMA by the agency.

(iv) The report that is provided must be in the form and format specified by OPWDD or in a similar format developed by the agency

(v) The report that is provided must not include names of anyone who is involved in the incident or occurrence or the investigation, or who is interviewed as a part of the investigation, or any information tending to identify such parties. Names of any such parties as well as any information tending to identify those parties must be excluded or redacted.

(9) The following documentation must be maintained:

(i) the telephone notice and responses received, including the identity and position of the party providing the notice, the name of the party receiving the notice, the time of the original call or attempted call, the time of subsequent attempted calls if the initial call was not successful and the time of follow up calls if the notice occurred in more than one call;

(ii) any requests for a meeting or the initial incident/occurrence report;

(iii) meetings held in response to the request, and those present;

(iv) when the report on actions taken and any requested written initial incident/occurrence report was provided;

(v) a copy of the report on actions taken and any initial incident/occurrence report (with redaction) that was provided; and

(vi) advice that a particular party does not want to receive notifications or that the capable adult receiving services objects to notice or objects to the provision of documents/ information.

(10) For the purpose of redaction as specified in this subdivision and section 624.8 of this Part only, the term employee means any party who is, or formerly was:

(i) directly employed by an agency; or

(ii) used by an agency to provide services substantially similar to those that are or could be provided by someone who is directly employed by an agency. Such parties include, but are not limited to: those who are employed by other entities on behalf of an agency and/or for the care and treatment of the person receiving services; consultants; contractors; or volunteers; or

(iii) a family care provider or family care substitute/respite provider; or a party living in the home of the provider.

(g) For the Willowbrook class, agencies must comply with the incident reporting requirements of the Willowbrook Permanent Injunction, dated March 11, 1993.

(h) The individual's service coordinator (e.g. a Medicaid Service Coordinator or Plan of Care Support Services Service Coordinator, or Willowbrook Service Coordinator) must be notified by the agency of all reportable incidents and notable occurrences involving any individual receiving non-ICF services that are certified, funded, or operated by OPWDD and must be provided with subsequent information, as follows:

(1) The service coordinator must be notified within 24 hours of the completion of the initial incident/occurrence report (for minor notable occurrences) or entry of initial information in IRMA. The notification must include a description of immediate protections.

(2) The service coordinator must be provided with subsequent information that may be needed to update an individual's plan of services and to monitor protective, corrective, and other actions taken following a reportable incident or occurrence. Specifically:

(i) The service coordinator must be provided with written information identifying investigative conclusions (including the findings of a report of abuse or neglect) and recommendations pertaining to the individual's care, protection, and treatment. The information provided must exclude information that directly or indirectly identifies agency employees, consultants, contractors, volunteers, or other individuals receiving services. This information must be provided to the service coordinator within:

(a) 10 days after completion of the investigation if the investigation was completed by the agency; or

(b) 10 days after the agency receives notice of the results of an investigation conducted by the Central Office of OPWDD or the Justice Center.

(ii) If the IRC review results in additional findings, conclusions, or recommendations regarding the individual's care, protection, and/or treatment, this information must be provided to the service coordinator, in written form, within 3 weeks after committee review.

(iii) If the Justice Center's review of an investigation conducted by the agency or by the Central Office of OPWDD results in additional findings, conclusions, or recommendations regarding the individual's care, protection, and/or treatment, this information must be provided to the service coordinator, in written form, within 10 days after the agency's receipt of the information.

(iv) The service coordinator may request additional information concerning the incident or occurrence in order to monitor protective, corrective, and/or other actions taken. In the event that an agency receives a request for this information from a service coordinator, the agency shall provide information that it deems appropriate. In providing this information, the agency must exclude information that directly or indirectly identifies agency employees, consultants, contractors, volunteers, and other individuals receiving services. If an agency determines that it would be inappropriate to disclose specific information requested, the agency must advise the service coordinator of this determination and its justification, in writing, within 10 days after the request. If the agency does not have specific information requested by the service coordinator (e.g. if the Justice Center conducted the investigation and it has not provided that information to the agency) the agency shall advise the service coordinator that it does not have the requested information.

Note: A service coordinator may be permitted to access information related to substantiated reports in accordance with section 496 (2)(n) of the Social Services Law.

(3) If the service coordinator is identified as the subject of a report of abuse or neglect or as a witness to a reportable incident or occurrence, the agency must not provide information to that party. In such a case, notifications and written information identified in paragraphs (1) and (2) of this subdivision must be provided to the service coordinator's supervisor or the administrator of the agency providing service coordination in lieu of the service coordinator.

(i) The individual's Qualified Intellectual Disabilities Professional (QIDP) and (if the person is a Willowbrook class member), the Willowbrook Case Services Coordinator (WCSC) must also be notified by the agency of all reportable incidents and occurrences involving any individual who resides in an Intermediate Care Facility that is operated or certified by OPWDD. The QIDP and WCSC must also be provided with subsequent information. Information must be provided to the QIDP and WCSC in the same manner that the information is provided to the Non-ICF service coordinator, in accordance with paragraphs 624.6(h)(1) and (2). If the QIDP or WCSC is identified as the alleged abuser, or is a witness to an incident or alleged abuse, the required notifications and subsequent information must be provided to the QIDP's or WCSC's supervisor or the administrator of the agency providing the residential or WCSC services, in lieu of the QIDP or WCSC.

Note: A service coordinator (including a QIDP performing that function) may be permitted to access information related to substantiated reports in accordance with Section 496 (2)(n) of the Social Services Law.

(j) Administrative appeal process - denial of requested records/documents.

(1) A requestor denied access to the initial incident/occurrence report or report on actions taken may appeal in writing such denial to the incident records appeals officer designated by the commissioner of OPWDD.

(2) Upon receipt of the appeal, the agency issuing the denial will be notified of the appeal and given an opportunity to submit relevant information to the incident records appeals officer, including the reasons for denial, within 10 business days of the receipt of such appeal. The incident records appeals officer may also request additional information from the requestor as may be necessary to resolve the appeal.

(3) Within 10 business days of the receipt of complete information, the incident records appeals officer will make a determination about whether the requested documents should be released. The incident records appeals officer will issue his or her determination with an explanation of the reasons for the determination to the requestor and the agency. If so directed by the incident records appeals officer, the agency must provide the requested records and/or documents to the requestor.

(k) It is the responsibility of a designated staff member of the agency where a report on a reportable incident or notable occurrence is received or made out, to notify any other agency where the person receives services of that reportable incident or notable occurrence if the incident or occurrence resulted in visible evidence of injury to the person, may be of concern to another agency, or may have an impact upon programming or activities provided by another agency.

(l) Notwithstanding any other provision in this Part, reports of Obstruction of reports of reportable incidents (see paragraph 624.3(b)(6)) that are reported to the Justice Center and/or OPWDD are not subject to the notification requirements in this section.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 624.6

Amended New York State Register December 2, 2015/Volume XXXVII, Issue 48, eff. 12/2/2015

Amended New York State Register May 9, 2018/Volume XL, Issue 19, eff. 5/9/2018