ASA-20-16-00004-A Incident Reporting in Oasas Certified, Licensed, Funded, or Operated Services

7/27/16 N.Y. St. Reg. ASA-20-16-00004-A

NEW YORK STATE REGISTER

VOLUME XXXVIII, ISSUE 30

July 27, 2016

RULE MAKING ACTIVITIES

OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES

NOTICE OF ADOPTION

 

I.D No. ASA-20-16-00004-A

Filing No. 649

Filing Date. Jul. 07, 2016

Effective Date. Jul. 27, 2016

Incident Reporting in Oasas Certified, Licensed, Funded, or Operated Services

PURSUANT TO THE PROVISIONS OF THE State Administrative Procedure Act, NOTICE is hereby given of the following action:

Action taken:

Amendment of Part 836 of Title 14 NYCRR.

Statutory authority:

Mental Hygiene Law, sections 19.09(b), 19.20, 19.20-a, 19.40, 32.02; Executive Law, section 296(15) and (16); Corrections Law, art. 23-A; Civil Service Law, section 50; Protection of People with Special Needs Act, L. 2012, ch. 501

Subject:

Incident Reporting in Oasas Certified, Licensed, Funded, or Operated Services.

Purpose:

To clarify requirements for reporting patient deaths.

Text of final rule:

Section 1. Subdivisions (a) and (b) of section 836.4 of Part 836, as adopted December 9, 2015, are amended to read as follows:

(a) (1) “Incident” means an event or happening, accident or injury during the conduct of any program activity which involves a client, a custodian, or damage to the facility in which the program operates and which has, or may have, an adverse or endangering effect on the life, health or welfare of clients or custodians and is required to be reported, investigated and recorded to designated parties according to Article eleven of the social services law and procedures approved by the Office, reviewed by an Incident Review Committee, and acted upon in an appropriate manner to safeguard the well-being of clients and custodians and to bring the matter to closure.

(2) Incidents are either “reportable” to the Justice Center or “non-reportable.” [Reportable incidents include incidents of “abuse and neglect” and “significant incidents” as such terms are defined in this section.]

(3) “Non-reportable” incidents need not be reported to the Justice Center, or if they are reported may be determined as not within the jurisdiction of the Justice Center; nevertheless, these incidents may require documentation in a patient’s clinical record or as an incident related to the program or facility which must be maintained by the service provider for review by the provider’s Incident Review Committee, or by the Office or the Justice Center, upon request.

(b) "Reportable incident" means an incident of “abuse or neglect” or a “significant incident” as defined in subdivision (c) or (d) of this section; some patient deaths are also a reportable incident.

§ 2 Paragraph 3 of subdivision (d) of section 836.4 of Part 836, as adopted December 9, 2015, is amended by adding a new subparagraph (vii) to read as follows:

(3) Other significant incidents, including but not limited to:

(i) An event that is, or appears to be, a crime under New York state or federal law involving custodians, clients, or others, including children of service recipients in a residential program, as victims or perpetrators;

(ii) Body cavity search; must be with client consent;

(iii) Any violation of a client’s rights to confidentiality pursuant to 42 CFR Part 2 or the Health Insurance Portability and Accountability Act (HIPAA).

(iv) Missing client as defined in subdivision (u) of this section;

(v) Suicide attempt whether or not preceded by statements of intent; statement of intent alone is not a suicide attempt; statements of intent should be recorded in a patient’s clinical record;

(vi) Death of a custodian or mandated reporter during the course of his/her job duties related to the provider facility; shall also be reported to any other appropriate entity[.];

(vii) Death of an outpatient client if death occurs on program premises or during the course of program activities.

§ 3 Subdivision (c) of section 836.8 of Part 836, as adopted December 9, 2015, is amended to read as follows:

(c) In the [case of a client’s death] event of a client’s death in an inpatient or residential program under any circumstances or within 30 days of such client’s discharge, immediate notification must be made to the VPCR (subject to the provisions of 42 CFR Part 2), the local coroner or medical examiner, or any other state or local agency identified under state laws requiring the collection of health or other vital statistics.

Final rule as compared with last published rule:

Nonsubstantive changes were made in section 836.4(b).

Text of rule and any required statements and analyses may be obtained from:

Sara E. Osborne, Associate Attorney, NYS Office of Alcoholism and Substance Abuse Services, 1450 Western Ave., Albany, NY 12203, [phone], email: [e-mail]

Revised Regulatory Impact Statement

OASAS is not submitting a revised Regulatory Impact Statement (RIS) for the adoption of this rulemaking because the non-substantive change to the text from the proposed rulemaking does not change the substance of the previously submitted Impact Statement.

Revised Regulatory Flexibility Analysis

OASAS has determined that the rule will not impose any adverse economic impact or reporting, recordkeeping or other compliance requirements on small businesses or local governments. This rulemaking proposal has been reviewed by the Behavioral Health Services Advisory Council consisting of affected OASAS providers of all sizes from diverse municipalities, and including local governments. The proposal is supported by providers because it will minimize reporting requirements, requires no new staff, cost or regulatory requirements.

The proposed rule is posted on the agency website; agency review process involves input from trade organizations representing providers in diverse geographic locations. The Office has prepared guidance documents for provider use and for training of agency administration.

Revised Rural Area Flexibility Analysis

OASAS is not submitting a revised Statement in Lieu of Rural Area Flexibility Analysis for these amendments because the non-substantive change to the text from the proposed rulemaking does not change the substance of the previously submitted Statement in Lieu of Rural Area Flexibility Analysis.

Revised Job Impact Statement

OASAS is not submitting a revised No Job Impact Statement for these amendments because the non-substantive change to the text from the proposed rulemaking does not change the substance of the previously submitted No Impact Statement.

Assessment of Public Comment

The agency received no public comment.