Section 5122-14-14 - Incident notification and risk management(A) This rule establishes standards to ensure the prompt and accurate notification of certain prescribed incidents. It also mandates the agency to review and analyze all incidents so that it might identify and implement corrective measures designed to prevent recurrence and manage risk.(B) Definitions (1) "Incident" means an event that poses a danger to the health and safety of patients and/or staff and visitors of the hospital, and is not consistent with routine care of persons served or routine operation of the hospital.(2) "Reportable incident" means an incident that needs to be submitted to the department, including incidents that are then to be forwarded by the department to disability rights Ohio. As referenced in division (E) of section 5119.36 of the Revised Code, "major unusual incident" has the same meaning as "reportable incident."(3) "Six month reportable incident" means an incident type of which limited information is to be reported to the department. A six month reportable incident is not the same as a reportable incident.(4) "Six month incident data report" means a data report that is to be submitted to the department.(C) The inpatient psychiatric service provider is to develop an incident reporting system to include a mechanism for the review and analysis of all reportable incidents such that clinical and administrative activities are undertaken to identify, evaluate, and reduce risk to patients, staff, and visitors. The inpatient psychiatric service provider is to identify in policy other incidents to be reviewed and analyzed. (1) An incident report is to be submitted in written form to the inpatient psychiatric service provider's chief executive officer or designee within twenty- four hours of discovery of the incident.(2) As part of the inpatient psychiatric service provider's performance improvement process, a periodic review and analysis of reportable incidents, and other incidents as defined in policy, is to be performed.(3) The inpatient psychiatric service provider is to maintain an ongoing log of its reportable incidents for departmental review.(D) Any person who has knowledge of an instance of abuse or neglect of a child or adolescent, or alleged or suspected abuse or neglect of a child or adolescent, or of an alleged crime committed against a child or adolescent that would constitute a felony is to immediately notify the appropriate public children's services agency or law enforcement authorities in accordance with section 2151.421 of the Revised Code. Even if the person has knowledge of an alleged crime against a child or adolescent committed by another child or adolescent, the person is to immediately notify law enforcement authorities.
(E) Any person who has knowledge of an instance of abuse or neglect of an elderly person, or alleged or suspected abuse or neglect of an elderly person, or of an alleged crime committed against an elderly person that would constitute a felony is to immediately notify the appropriate law enforcement and county department of job and family services authorities in accordance with section 5101.63 of the Revised Code.(F) Each inpatient psychiatric service provider is to submit reportable incidents and six month reportable incidents as defined by and in accordance with the schedule included in appendix A to this rule.(G) Each reportable incident is to be reported electronically through the web enabled incident reporting system (WEIRS) as mandated by the department, and is to be forwarded to the department within twenty-four hours of its discovery, exclusive of weekends and holidays. The WEIRS form is to include identifying information about the inpatient psychiatric service provider, date, time and type of incident, and client information that has been de-identified pursuant to the HIPAA privacy regulationsspecified in 45 C.F.R. 164.514(b)(2).(1) The inpatient psychiatric service provider is to file only one incident form per event occurrence and identify each incident report category, if more than one, and include information regarding all involved patients, staff, and visitors.(2) The inpatient psychiatric service provider is to notify the patient's parent, guardian, or custodian, if applicable, within twenty-four hours of discovery of a reportable incident and document such notification. (a) Notification may be made by phone, mailing, faxing or e-mailing a copy of the incident form, or other means according to inpatient psychiatric service provider policy and procedures.(b) When notification does not include sending a copy of the incident form, the inpatient psychiatric service provider is to inform the parent, guardian, or custodian, of his or her right to receive a copy and forward a copy within twenty-four hours of receiving a request for a copy. The inpatient psychiatric service provider is to document compliance with the provisions of this paragraph.(H) Each inpatient psychiatric service provider is to submit a six month incident data report to the department utilizing the form in WEIRS. The six month data report is to be submitted according to the following schedule:
(1) The six month data report for the period of January first to June thirtieth of each year is to be submitted no later than July thirty-first of the same year; and(2) The six month data report for the period of July first to December thirty-first of each year is to be submitted no later than January thirty-first of the following year.(I) The department may initiate follow-up and further investigation of a reportable incident or six month reportable incident as deemed necessary and appropriate, or may request such follow-up and investigation by the inpatient psychiatric service provider and/or regulatory or enforcement authority. Click to view Appendix
Click to view Appendix
Click to view Appendix
Ohio Admin. Code 5122-14-14
Effective: 4/24/2024
Five Year Review (FYR) Dates: 1/19/2024 and 04/24/2029
Promulgated Under: 119.03
Statutory Authority: R.C. 5119.33
Rule Amplifies: R.C. 5119.33
Prior Effective Dates: 10/12/1978, 01/01/1991, 01/01/2000, 11/01/2005, 01/01/2012, 02/17/2017