MRD-03-08-00002-E Notification of Incidents and Access to Records
1/16/08 N.Y. St. Reg. MRD-03-08-00002-E
NEW YORK STATE REGISTER
VOLUME XXX, ISSUE 3
January 16, 2008
RULE MAKING ACTIVITIES
OFFICE OF MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES
EMERGENCY RULE MAKING
I.D No. MRD-03-08-00002-E
Filing No. 1444
Filing Date. Dec. 28, 2007
Effective Date. Dec. 30, 2007
Notification of Incidents and Access to Records
PURSUANT TO THE PROVISIONS OF THE State Administrative Procedure Act, NOTICE is hereby given of the following action:
Action taken:
Addition of section 624.8 and amendment of sections 624.1, 624.2, 624.3, 624.4, 624.5, 624.6 and 624.20 of Title 14 NYCRR.
Statutory authority:
Mental Hygiene Law, sections 13.07, 13.09(b), 33.23 and 33.25 (L. 2007, chs. 24 and 271)
Finding of necessity for emergency rule:
Preservation of public health, public safety and general welfare.
Specific reasons underlying the finding of necessity:
The emergency regulations expand upon the provisions of Jonathan's Law to require notification of advocates and correspondents who are not “qualified persons” when incidents occur and allegations of abuse are made. The emergency regulations also expand upon the statutory provisions by extending the requirements from only certified facilities to all programs and services in the OMRDD system.
The additional incident notifications resulting from the new regulatory requirements will create new opportunities for oversight by the individuals who are notified. Through notification, these individuals are better able to monitor whether the health and safety needs of individuals are properly addressed and whether appropriate steps are being taken to remedy potentially harmful conditions which may have contributed to the incident. Without the promulgation of these regulations on an emergency basis, the additional monitoring enabled by the requirements would not occur until such time as the regulations could be finalized through the regular rulemaking process. During this period of time, potentially harmful situations that might have been remedied through the additional oversight could persist and adversely affect the health, safety and welfare of people receiving services.
Subject:
Notification of incidents and access to records.
Purpose:
To implement Mental Health Law sections 33.23 and 33.25 (chapters 24 and 271 of the Laws of 2007) concerning incident notifications and records and documents pertaining to allegations and investigations of abuse. The regulations require notification of certain incidents and allegations of abuse and associated follow-up activities. Additionally the rule provides for the release of records and documents pertaining to allegations and investigations of abuse.
Substance of emergency rule:
Effective December 30, 2007. Replaces similar emergency regulations that were effective October 1, 2007.
The following changes were made compared to the October 1, 2007 emergency regulations:
(1) Serious reportable incidents classified as “missing person” are now subject to the Jonathan's Law notifications.
(2) Service coordinators must be notified of all reportable incidents, serious reportable incidents and allegations of abuse. This has been a longstanding OMRDD policy and is now included in regulation.
(3) Language was clarified related to the time that an alleged abuse case is closed (which starts the 21 day clock for release of documents and records in Section 624.8). The December 30 emergency regulations, paragraph 624.8(e)(2).
(4) The use of a diagnostic procedure (e.g., x-ray) when the results are negative (e.g., nothing broken) is no longer considered a reportable injury.
(5) An old requirement for a “written preliminary finding” within 24 hours of the occurrence or discovery has been eliminated.
General:
The regulations amend existing OMRDD regulations on incidents and abuse (Part 624).
The regulations apply to all facilities and services operated, certified, authorized or funded through contract by OMRDD. This includes residential facilities, day programs, HCBS waiver services, and Medicaid Service Coordination.
New notification and disclosure requirements do not apply to events or situations which are not under the auspices of the agency, such as allegations of abuse by family members in private residences. Requirements that agencies intervene and take appropriate action in these events or situations are unchanged.
The OMR 147(I) and OMR 147(A) are removed from the regulation. OMRDD is replacing these forms with a single revised form.
The OMR 147 must be used for all reportable incidents, serious reportable incidents and allegations of abuse.
Full documentation of compliance is required.
Existing requirements are unchanged for notification to CQCAPD, law enforcement officials, Statewide Central Register of Child Abuse and Maltreatment, etc.
For the Willowbrook class, agencies must continue to comply with the incident reporting requirements of the Willowbrook Permanent Injunction.
An old requirement for a “written preliminary finding” within 24 hours of the occurrence or discovery has been eliminated. The OMR 148 or equivalent report on actions taken takes the place of the written preliminary finding.
The use of a diagnostic procedure (e.g., x-ray) when the results are negative (nothing broken) is no longer considered a reportable injury.
Service coordinators must be notified of all reportable incidents, serious reportable incidents and allegations of abuse whether or not the event or situation is “under the auspices” of the agency or sponsoring agency.
Regulations to implement Section 33.23 MHL:
The regulations build on notification requirements in pre-existing OMRDD regulations, which required notification of serious reportable incidents and allegations of abuse to guardians, parents and advocates/correspondents.
The following types of events/situations are subject to the new requirements:
(–) Reportable incidents in the categories of injury, medication error and death.
(–) Serious reportable incidents in the categories of injury, missing person, medication error and death.
(–) All allegations of abuse.
Current notification requirements are maintained for serious reportable incidents which are in the other categories (restraint, possible criminal act, and sensitive situation). Notification must occur within 24 hours of completion of the OMR 147.
Neither notification nor disclosure is required for reportable incidents in the category of sensitive situation or for events/situations which do not rise to the level of reportable incidents (e.g., “agency reportable incidents”).
The new requirements require notification to one of the following: guardian, parent, spouse or adult child.
Exceptions:
(–) The guardian, parent, spouse or adult child objects to notification to himself or herself.
(–) The person receiving services is a capable adult who objects to the notification being made to someone else.
(–) The person who would otherwise be notified is the alleged abuser.
If there is no guardian, parent, spouse or adult child (or they are unavailable), but the person has an advocate or correspondent, notification should be made to that individual in the same manner. Advocates/correspondents must also be offered a meeting and must be sent the report on actions taken. Upon request, advocates/correspondents must be sent the redacted OMR 147. (Note: the advocate or correspondent is not eligible to request disclosure of the investigation report and other investigation documents).
If there is no guardian, parent, spouse or adult child (or they are unavailable), and the person receiving services is a “capable adult” as defined in the regulations, the person receiving services must be notified. In addition, the person receiving services must be offered a meeting and must receive the report on actions taken.
The notification must be by telephone or in person, or by other methods at the request of the recipient of the notice.
The notification must be made within 24 hours of the completion of the OMR 147.
The notice must include:
(–) A description of the event or situation and a description of initial actions taken to address the incident or alleged abuse, if any,
(–) An offer to meet with the chief executive officer or designee, and
(–) For allegations of abuse, an offer to provide information on the status and resolution of the allegation (this is a pre-existing requirement).
Upon request, a copy of the OMR 147 reporting form must be provided to the person receiving services, guardian, parent, spouse, adult child, or advocate/correspondent. Records must be redacted.
The agency must provide a written report on actions taken to address the incident or alleged abuse for every incident and allegation subject to the new notification process.
(–) The report must be provided to the individual that was notified.
(–) The report must include: any immediate steps taken in response to the incident or alleged abuse to safeguard the health or safety of the person receiving services, and a general description of any initial medical or dental treatment or counseling provided to the person in response to the incident or alleged abuse.
(–) The report must be on a form developed by OMRDD or a similar agency form.
(–) The report must be provided within 10 days of the completion of the OMR 147.
(–) The report on actions taken cannot include names of others involved in the incident/allegation or investigation or information tending to identify them.
Regulations to implement Section 33.25 MHL:
The regulations require the release of records and documents pertaining to allegations and investigations into abuse under the auspices of the agency.
Only guardians, parents, spouses and adult children who are considered to be a “qualified person” according to the definition in the Mental Hygiene Law, are eligible to receive records.
If the otherwise eligible requestor is the alleged abuser he or she is not eligible to receive records.
If the consumer is a capable adult and objects to the release of records, the otherwise eligible requestor is not eligible to receive records.
Requests must be in writing.
Documents and records must be released 21 days after the closure of the alleged abuse case or 21 days after the request, if the request is made after closure. For purposes of determining when the 21 day clock begins, closure is considered the time when the standing committee has ascertained that no further investigation is necessary and a conclusion is reach whether the allegation is substantiated, disconfirmed or inconclusive.
Records must be redacted.
A small window of retroactivity established by law (Chapter 271 of the Laws of 2007) allows requests for records related to allegations of abuse which occurred or were discovered on or after January 1, 2003 but prior to May 5, 2007. Requests for these records must be made by December 31, 2007.
Except as noted above, agencies are only required to release records pertaining to allegations of abuse which occurred or were discovered on or after May 5, 2007.
Records may not be redisclosed by recipients.
Redaction (applicable to the release of documents and records pursuant to Section 33.25 MHL and the OMR 147). The following should be redacted:
Names or other information tending to identify people receiving services and employees. Redaction shall be waived if the employee or person receiving services authorizes disclosure (unless redaction is needed because the information would tend to identify a different person whose identity is shielded by the regulations). The definition of employee is very inclusive, but only for the purposes of redaction of these records in compliance with the new law and the implementing regulations. It includes consultants, contractors, volunteers, family care providers and family care respite/substitute providers, and individuals who live in home of the provider.
Names or other information tending to identify anyone who made a report to the Statewide Central Register of Child Abuse and Maltreatment (SCR), contacted the SCR, or otherwise cooperated in a child abuse/maltreatment investigation.
This notice is intended
to serve only as a notice of emergency adoption. This agency intends to adopt this emergency rule as a permanent rule and will publish a notice of proposed rule making in the State Register at some future date. The emergency rule will expire March 26, 2008.
Text of emergency rule and any required statements and analyses may be obtained from:
Barbara Brundage, Director, Regulatory Affairs Unit, Office of Mental Retardation and Developmental Disabilities, 44 Holland Ave., Albany, NY 12229, (518) 474-1830; e-mail: barbara.brundage@omr.state.ny.us
Additional matter required by statute:
Pursuant to the requirements of the State Environmental Quality Review Act (SEQRA) and in accordance with 14 NYCRR Part 622, OMRDD has on file a negative declaration with respect to this action. Thus, consistent with the requirements of 6 NYCRR Part 617, OMRDD, as lead agency, has determined that the action described herein will not have a significant effect on the environment, and an environmental impact statement will not be prepared.
Regulatory Impact Statement
1. Statutory Authority:
a. The New York State Office of Mental Retardation and Developmental Disabilities' (OMRDD) statutory responsibility to assure and encourage the development of programs and services in the area of care, treatment, rehabilitation, education and training of persons with mental retardation and developmental disabilities, as stated in Section 13.07 of the New York State Mental Hygiene Law.
b. OMRDD's authority to adopt rules and regulations necessary and proper to implement any matter under its jurisdiction as stated in Section 13.09(b) of the Mental Hygiene Law.
c. Section 33.23 of the Mental Hygiene Law, which requires specific incident notifications and the release of specified reports.
d. Section 33.25 of the Mental Hygiene Law, which requires the release of records and documents pertaining to allegations and investigations of abuse.
2. Legislative Objectives: These amendments further the legislative objectives embodied in sections 13.07, 13.09(b), 33.23 and 33.25 of the Mental Hygiene Law. The promulgation of these amendments will provide a more extensive notification process for certain incidents and allegations of abuse. In addition, the amendments provide greater access by specified individuals to records and documents pertaining to allegations and investigations of abuse.
3. Needs and Benefits: Chapter 24 of the Laws of 2007 (MHL Sections 33.23 and 33.25), otherwise known as “Jonathan's Law,” was signed by the Governor on May 5, 2007 and was effective immediately. A chapter amendment to the new law, Chapter 271 of the Laws of 2007, was signed on July 18.
The regulatory amendments are necessary to implement the new laws and to make longstanding OMRDD regulations related to incidents and abuse consistent with the statutory requirements. In addition, these amendments clarify ambiguities in the law, as well as provide more specific direction and guidance to providers so that implementation is more effective and consistent statewide. Further, the regulations build on the notification process requirements established by statute to extend certain provisions to advocates and correspondents who are not “qualified persons” and to require compliance by all providers in the OMRDD system, not just “facilities” as specified in the law.
The new law and the associated regulations require providers to implement a more extensive notification process for certain incidents and all allegations of abuse. This notification process will provide timely information about incidents that affect the health or safety of a person receiving services to the following: a person's guardian, parent, spouse, adult child or advocate/correspondent. In addition to an initial telephone notification, the individual will have access to the initial incident/allegation of abuse report, will be provided a report on initial actions taken and will be offered the opportunity to meet with the agency Chief Executive Officer/DDSO Director (or a designee) to discuss the incident or allegation of abuse.
The law and implementing regulations also provide a qualified person with access to records and documents pertaining to allegations and investigations of abuse. For this purpose a qualified person is defined in Mental Hygiene Law 33.16 and may include: persons receiving services or who formerly received services; and guardians, parents, spouses and adult children of such persons. The regulations extend applicability of the new requirements from only events occurring “at a facility” as specified by statute to allegations of abuse occurring while individuals are receiving facility-based services at a location away from the facility. In addition, the regulations extend applicability to services in the OMRDD system which are not facility-based, such as at-home residential habilitation and supported employment. OMRDD considers that allegations of abuse by employees should be treated the same regardless of the type of service received or location of service delivery.
4. Costs:
a. The amendments impose minor additional costs beyond the cost of complying with the new laws. Compliance with the new laws will likely require additional expenditures for personnel, paperwork, phone charges and postage. Although pre-existing OMRDD regulations already required notification of some types of incidents and allegations of abuse, the law requires notification (with its attendant costs) of additional incidents. In addition, the law requires that a report on actions taken be provided for each incident and allegation of abuse subject to the new notification requirements. Additional meetings may occur as a result of the mandated offer to hold a meeting. Lastly, documents and records must be provided upon request and must be redacted in accordance with the law.
While the statute limited the individuals being notified to “qualified persons,” the regulations extended the new notification process requirements to include advocates and correspondents. While advocates and correspondents were required to be notified of some incidents by the pre-existing OMRDD regulations, minor additional costs will be incurred through both notification of additional incidents and through the additional features of the notification process imposed by Jonathan's Law, such as the provision of the report on actions taken.
In addition, the statute only applied to allegations of abuse occurring at a facility. However, providers in the OMRDD system operate many services which are not “facilities,” such as service coordination, supported employment, and at-home residential habilitation. The OMRDD regulations extended the requirements of Jonathan's Law to include all services in the OMRDD system, as well as allegations of abuse when individuals are receiving facility-based services at a location away from the facility. This extension applies to both the notification process and the eligibility to request records and documents pertaining to allegations and investigations of abuse.
OMRDD is unable to quantify the modest additional costs that will be incurred by these extensions of the statutory requirements.
b. OMRDD will incur additional costs as a provider of state-operated services as noted above. These additional costs cannot be quantified.
OMRDD will use existing staff to administer this rule and does not anticipate any significant expenditure related to its administration. There are minimal additional expenditures related to informing and training providers of both Jonathan's Law and the implementing regulations.
c. There will be no additional costs to local governments.
5. Local Government Mandates: There are no new requirements imposed by the rule on any county, city, town, village; or school, fire, or other special district.
6. Paperwork: Compliance with the new laws entails an increase in paperwork. The new law requires that a written report on actions taken be provided for every incident that is subject to the new requirements. OMRDD has developed a new form to assist agencies in providing this report. Agencies are also required to provide redacted incident reports upon request as a part of the notification process. Further, agencies are required to provide redacted records and documents pertaining to allegations and investigations into abuse. The regulations add minimal new paperwork requirements to the statutory requirements by extending provisions related to the notification process to include advocates and correspondents, and extending requirements to encompass all services in the OMRDD system and incidents related to facility-based programs which occur in community settings with staff.
7. Duplication: The regulatory amendment does not duplicate existing state or federal requirements.
8. Alternatives: The law only requires the notification requirements to be made to a qualified person as defined in MHL 33.16. “Qualified persons” include only guardians, parents, spouse or adult child. OMRDD had considered limiting the applicability of the notification requirements to “qualified persons.” However, OMRDD recognizes the valuable role played by siblings, family members, friends and others who are advocates and correspondents but who are not “qualified persons.” OMRDD considers that individuals without a “qualified person” who have an advocate or correspondent should also be able to benefit from the additional notification process requirements. OMRDD consequently extended the new notification process requirements to include advocates/correspondents.
9. Federal Standards: The amendments do not exceed any minimum standards of the federal government for the same or similar subject areas.
10. Compliance Schedule: OMRDD filed a similar emergency regulations on October 1, 2007.
OMRDD intends propose similar regulations in the future and to finalize regulations within the time frames provided for by the State Administrative Procedure Act (SAPA).
Regulatory Flexibility Analysis
1. Effect on small business: These regulatory amendments will apply to providers of services that operate all programs certified, authorized or approved by OMRDD.
OMRDD has determined, through a review of the certified cost reports, that the organizations which operate the facilities or provide the developmental disabilities services employ fewer than 100 employees at the discrete certified or authorized sites and would, therefore, be classified as small businesses.
The amendments have been reviewed by OMRDD in light of their impact on these small businesses and on local governments. OMRDD has determined that these amendments will not cause undue hardship to small business providers due to increased costs for additional services or increased compliance requirements.
2. Compliance requirements: The new law required a variety of compliance activities. These activities include: providing telephone notice to a qualified person for certain incidents and allegations of abuse, offering a meeting with the agency's Chief Executive Officer or DDSO Director or a designee, and offering to provide a written report on actions taken. In addition, upon the request of a qualified person, documents and records pertaining to allegations and investigations of abuse must be released. All the above referenced documents must have names and identifying information redacted. The implementing regulations extend the requirements to advocates and correspondents, to non-facility based services and to situations when facility-based services are delivered at a location away from the facility. Agencies will need to make the changes needed for implementation in these situations where the regulatory requirements exceed the statutory requirements.
3. Professional services: Modest additional professional services are required as a result of these amendments, due to the need for the involvement of legal professionals in redaction and interpretation of the regulations, to the extent that the regulatory requirements exceed the statutory requirements. The amendments will have no effect on the professional service needs of local governments.
4. Compliance costs: There are no costs to local governments.
The amendments impose minor new compliance costs. There are minimal additional costs associated with implementation and compliance with the law. In the areas noted above where the regulatory requirements exceed the statutory requirements, these modest compliance costs will be increased as notification is required in new situations and in additional service types.
5. Economic and technological feasibility: The amendments do not impose on regulated parties the use of any technological processes.
6. Minimizing adverse economic impact: As stated in the Regulatory Impact Statement, the proposed regulation will have no fiscal effect on State or local governments, and minimal fiscal impact on regulated parties (including the state as a provider). Modest additional costs are necessary to the extent regulatory requirements exceed statutory requirements. OMRDD has reviewed and considered the approaches for minimizing economic impact as suggested in section 202-b(1) of the State Administrative Procedure Act. In order to minimize adverse economic impact, OMRDD has developed a standardized form for the report on actions taken. The use of this form will minimize staff resources devoted to completing the form, instead of each agency developing its own form or not using a form for this purpose.
7. Small business and local government participation: OMRDD convened a Jonathan's Law implementation workgroup which included representatives from provider associations. The group met on June 1, June 20 and November 7, 2007. Presentations were made to various groups including committees of the Cerebral Palsy Associations of New York State and the New York State Association of Residential and Community Agencies (NYSACRA). OMRDD staff presented at training sessions with hundreds of provider representatives hosted by NYSACRA on June 28 and July 20. OMRDD staff also presented at a training session hosted by the Long Island Alliance on August 23. In addition, OMRDD staff made a presentation at a meeting of the Conference of Local Mental Hygiene Directors on August 17. OMRDD also conducted a series of internal training sessions on October 3, October 11, October 18 and October 29. Informational mailings were sent to affected providers regarding the implementation of the new law on May 11 and May 15. A detailed informational mailing specifically discussing the emergency regulations was sent to providers and other interested parties on August 31. OMRDD also solicited comments from the Self-Advocacy Association, the Statewide Family Support Services Committee and the NYSARC Adult Services Committee. OMRDD informed all provider agencies, provider associations, and other interested parties (including parents, family members and individuals receiving services) of the October 1 emergency regulations by mail. In addition, numerous questions and comments were received from voluntary providers, local government representatives and others at the events noted above and through individual contact.
Rural Area Flexibility Analysis
A Rural Area Flexibility Analysis for these amendments is not submitted because the amendments will not impose any adverse impact or significant reporting, recordkeeping or other compliance requirements on public or private entities in rural areas because of the location of their operations (rural/urban). This finding is based on the fact that the proposed rule changes the way in which notifications are made regarding certain incidents and allegations of abuse. The proposed rule also provides greater access by qualified persons, including parents and legal guardians, to records and documents pertaining to allegations and investigations of abuse and mistreatment. OMRDD expects that adoption of the amendments will not have adverse effects on regulated parties because of the location of their operations. Further, the amendments will have no adverse fiscal impact on providers as a result of the location of their operations. Specific effects of the rule on providers of services have been discussed in the Regulatory Flexibility Analysis for Small Businesses and Local Governments.
Job Impact Statement
A Job Impact Statement for these amendments is not submitted because it is apparent from the nature and purposes of the amendments that they will not have an adverse impact on jobs and/or employment opportunities and they may have a slightly positive impact on employment opportunities due to new features in the rule. This finding is based on the fact that the regulatory requirements exceed the statutory requirements of Jonathan's Law to require modest additional notifications and access to records as noted in the Regulatory Impact Statement. It is anticipated that providers will generally utilize existing staff to accomplish these tasks. In unusual circumstances, providers may find it necessary to hire or contract for additional staff.
