Section 2060.385  Incident and Significant Incident Reporting

a)         An incident is any action that led to, or is likely to lead to, an adverse effect on client/patient/resident services because it is a deviation from established procedures.  These incidents shall be documented in writing immediately, reported to supervisory staff, as applicable, and available for review by DHS/SUPR staff as necessary or during inspection.

b)         A significant incident is any occurrence which, regardless of the type of service the client/patient/resident may be receiving:

1)         Requires the services of the coroner;

2)         Renders the facility inoperable;

3)         Involves the alleged sexual or physical abuse or assault of staff or a client/patient/resident;

4)         Involves any alleged act that requires mandatory reporting to the professional staff licensing or credentialing body; or

5)         Involves any sanction imposed against the licenses or certification of any professional staff member.

c)         DHS/SUPR shall be notified verbally in person or over the phone of any significant incident within 24 hours after its occurrence.

d)         A written report of any significant incident shall be submitted to DHS/SUPR within ten calendar days after the occurrence and, if applicable, a copy of the coroner's report shall be submitted within five calendar days of receipt by the organization or as part of submission of the written report.