TITLE 7 HEALTH
CHAPTER 1 HEALTH GENERAL PROVISIONS
PART 13 INCIDENT
REPORTING, INTAKE, PROCESSING AND TRAINING REQUIREMENTS
7.1.13.1 ISSUING AGENCY: New Mexico Department of Health.
[7.1.13.1 NMAC - Rp, 7.1.13.1 NMAC,
7/1/14]
7.1.13.2 SCOPE: This rule is applicable to persons,
organizations or legal entities to include each: adult day care center, adult
day care home, adult assisted living facility, ambulatory surgical center,
diagnostic and treatment center, end stage renal disease facility, general,
acute, special and limited service hospitals, home health agency, hospice
facility, hospital infirmary, intermediate care facility for the mentally
retarded or the intellectually and developmentally disabled, limited diagnostic
and treatment center, nursing facility,
skilled nursing facility, and rural
health clinic.
[7.1.13.2 NMAC - Rp, 7.1.13.2 NMAC,
7/1/14]
7.1.13.3 STATUTORY AUTHORITY: Department of Health Act, Subsection E of
Section 9-7-6 NMSA 1978 and Subsection D of Section 24-1-2, Subsections I, L,
O, T and U of Section 24-1-3, and 24-1-5 NMSA 1978, of the Public Health Act as
amended.
[7.1.13.3 NMAC - Rp, 7.1.13.3 NMAC,
7/1/14]
7.1.13.4 DURATION: Permanent.
[7.1.13.4 NMAC - Rp, 7.1.13.4 NMAC,
7/1/14]
7.1.13.5 EFFECTIVE DATE:
July 1, 2014, unless a later date is cited at the end of a section.
[7.1.13.5 NMAC - Rp, 7.1.13.5 NMAC,
7/1/14]
7.1.13.6 OBJECTIVE: This rule establishes standards for licensed
health care facilities to institute and maintain an incident management system
and employee training program for the reporting of abuse, neglect, exploitation
injuries of unknown origin and other reportable incidents.
[7.1.13.6 NMAC - Rp, 7.1.13.6 NMAC,
7/1/14]
7.1.13.7 DEFINITIONS:
A. “Abuse” means:
(1) knowingly,
intentionally, and without justifiable cause inflicting physical pain, injury
or mental anguish;
(2) the intentional
deprivation by a caretaker or other person of services necessary to maintain
the mental and physical health of a person;
(3) sexual abuse,
including criminal sexual contact, incest and criminal sexual penetration; or
(4) verbal abuse,
including profane, threatening, derogatory, or demeaning language, spoken or
conveyed with the intent to cause mental anguish.
B. “Bureau” means the department of health, division of health
improvement, health facility licensing and certification bureau.
C. “Case manager”
means the staff person designated to coordinate and monitor the individual
service plan for persons receiving services.
D. “Complaint” means any report,
assertion, or allegation of abuse, neglect, or exploitation of, or injuries of
unknown origin to, a consumer made by a reporter to the incident management
system, and includes any reportable incident that a licensed health care
facility is required to report under applicable law.
E. “CMS”
means the centers for medicare and medicaid services.
F. “Consumer” means any person who engages the professional services of a
medical or other health professional on an inpatient or outpatient basis, or
person requesting services from a hospital.
G. “Department” means the New Mexico department of health.
H. “Division” means the department of health, division of health
improvement.
I. “Employee” means:
(1) any
person whose employment or contractual service with a licensed health care
facility which includes direct care or routine and unsupervised physical or
financial access to any care recipient serviced by that licensed health care
facility; or
(2) any compensated
persons such as employees, contractors and employees of contractors; or
guardianship service providers or case management entities that provide
services to people with developmental disabilities; or administrators or
operators of facilities who are routinely on site.
J. “Exploitation” means an unjust or improper use of a person's money or
property for another person's profit or advantage, financial or otherwise.
K. “Immediate access” means physical or in person direct and unobstructed access,
to electronic or other access needed by employees, consumers, family members or
legal guardian to the licensed health care facility’s incident management
reporting procedures or access to the division’s incident report form.
L. “Immediate reporting” means reporting that is done as soon as practicable and no
later than twenty-four (24) hours from knowledge of the incident.
M. “Immediate jeopardy” means a provider's noncompliance with one (1) or more
requirements of medicaid or medicare participation, which causes or is likely
to cause, serious injury, harm, impairment, or death to a consumer.
N. “Incident” means any known, alleged or suspected event of abuse,
neglect, exploitation , injuries of unknown origin or other reportable
incidents.
O. “Incident management system” means the written policies and procedures adopted or
developed by the licensed health facility for reporting abuse, neglect,
exploitation, injuries of unknown origin or other reportable incidents.
P. “Incident report form” means the reporting format issued by the division for the
reporting of incidents or complaints.
Q. “ISP” means a consumer’s individual service plan.
R. “Licensed health care facilities” means any organization licensed by the department for the
following services: adult day care center, assisted living facility, ambulatory
surgical center, diagnostic and treatment center, end stage renal disease
facility, general, acute, special and limited service hospitals, home health
agency, hospice facility, hospital infirmary, intermediate care facility for
the mentally retarded or intellectually and developmentally disabled, limited
diagnostic and treatment center, nursing facility, skilled nursing facility, rural
health clinic.
S. “Mental anguish” means a relatively high degree of mental pain and distress
that is more than mere disappointment, anger, resentment or embarrassment,
although it may include all of these, and is objectively manifested by the
recipient of care or services by significant behavioral or emotional changes or physical symptoms.
T. “Neglect” means the failure of the caretaker to provide basic needs of a
person, such as clothing, food, shelter, supervision and care for the physical
and mental health of that person. Neglect causes, or is likely to cause, harm
to a person.
U. “Quality assurance” means a systematic approach to the continuous study and
improvement of the efficiency and efficacy of organizational, administrative
and clinical practices in meeting the needs of persons served as well as
achieving the licensed health care facility’s mission, values and goals.
V. “Quality improvement system” means the adopted or developed licensed health care
facility’s policies and procedures for reviewing and documenting all alleged
incidents of abuse, neglect, exploitation, injuries of unknown origin, or other
reportable incidents for the continuous study and improvement of the efficiency
and efficacy of organizational, administrative and preventative practices in
employee training and reporting.
W. “Reportable incident” means
possible abuse, neglect, exploitation, injuries of unknown origin and other
events including but not limited to falls which cause injury, unexpected death,
elopement, medication error which causes or is likely to cause harm, failure to
follow a doctor’s order or an ISP, or any other incident which may evidence
abuse, neglect, or exploitation.
X. “Reporter” means any person who or any entity that reports possible
abuse, neglect or exploitation to the division.
Y. “Restraints” means use of a mechanical device, or chemical restraints
imposed, for the purposes of discipline or convenience, to physically restrict
a consumer's freedom of movement, performance of physical activity, or normal
access to his body.
Z. “Revocation” means a type of sanction making a license null and void
through its cancellation.
AA. “Sanction”
means a measure imposed by the department on a licensed program, pursuant to
these requirements, in response to a finding of deficiency, with the intent of
obtaining increased compliance with these requirements.
BB. “Substantiated” means the verification of a
complaint based upon a preponderance of reliable evidence obtained from an
appropriate investigation of a complaint of abuse, neglect, or exploitation.
CC. “Suspension” means a temporary cancellation of a license pending an
appeal, hearing or correction of the deficiency. During a suspension the
provider's medicare or medicaid agreement is not in effect.
DD. “Training curriculum” means the instruction manual or pamphlet adopted or
developed by the licensed health facility containing policies and procedures
for reporting abuse, neglect, misappropriation of consumers' property or other
reportable incidents.
EE. “Unsubstantiated”
means that the complaint or incident could not be verified based upon a
preponderance of reliable evidence obtained from an appropriate investigation
of a complaint of abuse, neglect, or exploitation.
FF.“Volunteer” means any person who works
without compensation for a licensed health care facility whose services
includes direct care or routine and unsupervised physical or financial access
to any care recipient serviced by that
licensed health care facility.
[7.1.13.7 NMAC - Rp, 7.1.13.7 NMAC,
7/1/14]
7.1.13.8 INCIDENT MANAGEMENT SYSTEM REPORTING REQUIREMENTS
FOR LICENSED HEALTH CARE FACILITIES:
A. Duty to report:
(1) All licensed
health care facilities shall immediately report abuse, neglect or exploitation
to the adult protective services division.
(2) All licensed
health care facilities shall report abuse, neglect, exploitation, and injuries
of unknown origin or other reportable incidents to the bureau within a
twenty-four (24) hour period, or the next business day when the incident occurs
on a weekend or holiday.
(3) All licensed
health care facilities shall ensure that the reporter with direct knowledge of
an incident has immediate access to the bureau incident report form to allow
the reporter to respond to, report, and document incidents in a timely and
accurate manner.
B. Notification:
(1) Incident
reporting: Any person may report an incident to the bureau by
utilizing the DHI toll free complaint hotline at 1-800-752-8649. Any consumer,
employee, family member or legal guardian may also report an incident to the
bureau directly or through the licensed health care facility by written
correspondence or by utilizing the bureau’s incident report form. The incident
report form and instructions for the completion and filing are available at the
division's website, at
https://dhi.health.state.nm.us/elibrary/ironline/hflc_instructions.php or may
be obtained from the department by calling the toll free number at
1-800-752-8649.
(2) Division
incident report form and notification by licensed health care facilities:
The licensed health care facility shall report incidents utilizing the
division’s incident report form consistent with the requirements of the
division’s incident management system guide and CMS regulations as applicable.
The licensed health care facility shall ensure that all incident report forms
alleging abuse, neglect, exploitation, injuries of unknown origin or other
reportable incidents are submitted by a reporter with direct knowledge of an
incident, are completed on the bureau’s incident report form and received by
the division within twenty-four (24) hours of an incident or allegation of an
incident or the next business day if the incident occurs on a weekend or a
holiday. The licensed health care facility shall ensure that the reporter with
the most direct knowledge of the incident assists with the preparation of the
incident report form.
C. Incident policies: All licensed health care facilities shall maintain policies
and procedures which describe the licensed health care facility’s immediate
response to all reported allegations of abuse, neglect, exploitation, injuries
of unknown origin, and deaths, as applicable.
D. Retaliation: Any individual who, without false intent, reports an
incident or makes an allegation of abuse, neglect or exploitation will be free
of any form of retaliation.
E. Quality improvement system for
licensed health care facilities: The licensed health care
facility shall establish and implement a quality improvement system for
reviewing alleged complaints and incidents. The incident management system
shall include written documentation of corrective actions taken. The provider
shall maintain documented evidence that all alleged violations are thoroughly
investigated, and shall take all reasonable steps to prevent further incidents.
[7.1.13.8 NMAC - Rp, 7.1.13.8 NMAC,
7/1/14]
7.1.13.9 INCIDENT MANAGEMENT SYSTEM REQUIREMENTS:
A. General: All licensed health care facilities shall
establish and maintain an incident management system, which emphasizes the
principles of prevention and staff involvement. The licensed health care
facility shall ensure that the incident management system policies and
procedures requires all employees to be competently trained to respond to,
report, and document reportable incidents in a timely and accurate manner.
B. Training curriculum: Prior to working unsupervised with consumers, the licensed
health care facility shall provide all employees and volunteers with a written
training curriculum and shall train them on incident policies and procedures
for identification, and timely reporting of abuse, neglect, exploitation,
injuries of unknown origin or other reportable incidents. Refresher training
shall be provided at annual, not to exceed twelve (12) month, intervals. The
training curriculum may include computer-based training. Reviews shall include,
at a minimum, review of the written training curriculum and site-specific
issues pertaining to the licensed health care facility. Training shall be
conducted in a language that is understood by the employee and volunteer.
C. Incident management system training
curriculum requirements:
(1) The licensed health care facility shall
conduct training, or designate a knowledgeable representative to conduct
training, in accordance with the written training curriculum that includes but
is not limited to:
(a) an
overview of the potential risk of abuse, neglect, and exploitation;
(b) informational procedures for properly
filing the division's incident management report form;
(c) specific instructions of the employees’
legal responsibility to report an incident of abuse, neglect or exploitation;
(d) specific instructions on how to respond to
abuse, neglect, and exploitation; and
(e) emergency action procedures to be followed
in the event of an alleged incident or knowledge of abuse, neglect, or
exploitation.
(2) All current
employees and volunteers shall receive training within ninety (90) days of the
effective date of this rule.
D. Training documentation: All
licensed health care facilities shall prepare training documentation for each
employee to include a signed statement indicating the date, time, and place
they received their incident management reporting instruction. The licensed
health care facility shall maintain documentation of an employee's or
volunteer’s training for a period of at least twelve (12) months. Training
curricula shall be kept on the premises and made available on request by the
department. Training documentation shall be made available immediately upon a
department representative's request. Failure to provide employee or volunteer
training documentation shall subject the licensed health care facility to the
penalties provided for in this rule.
E. Consumer and guardian orientation
packet: Consumers, family members and legal
guardians shall be made aware of and have available immediate accessibility to
the licensed health care facility incident reporting processes. The licensed
health care facility shall provide consumers, family members or legal guardians
an orientation packet to include incident management systems policies and
procedural information concerning the reporting of abuse, neglect or
exploitation. The licensed health care facility shall include a signed
statement indicating the date, time, and place they received their orientation
packet to be contained in the consumer’s file. The appropriate consumer, family
member or legal guardian shall sign this at the time of orientation.
F. Posting of incident
management information poster:
All licensed health care facilities and shall post two (2) or more posters, to
be furnished by the division, in a prominent public location which states all
incident management reporting procedures, including contact numbers and
internet addresses. All licensed health care facilities operating sixty (60) or
more beds shall post at least three (3) or more posters, to be furnished by the
division, in a prominent public location which states all incident management
reporting procedures, including contact numbers and internet addresses. The
posters shall also be posted where employees report each day and from which the
employees operate to carry out their activities. Each licensed health care
facility shall take steps to ensure that the notices are not altered, defaced,
removed, or covered by other material.
[7.1.13.9 NMAC - Rp, 7.1.13.10 NMAC,
7/1/14]
7.1.13.10 ACCESS
AND COOPERATION TO FACILITATE DEPARTMENT INCIDENT INVESTIGATIONS:
A. The
department will conduct incident investigations and periodic surveys of
licensed health care facilities subject to these requirements. These reviews
may be either announced or unannounced.
B. All
licensed health care facilities shall facilitate immediate physical or
in-person access to department personnel investigating incidents or conducting
surveys:
(1) all records,
regardless of media, including but not limited to, financial records, all
client records, individual service plans, personnel records, board and or
committee minutes, incident reports, quality assurance activities, client
satisfaction surveys and agency policy /procedures manuals;
(2) all necessary
employees with direct knowledge of the incident;
(3) all necessary clients
currently receiving services, guardians, representatives and family members with direct knowledge of the incident; and
(4) all administrative
and service delivery sites.
C. All licensed
health care facilities shall conduct a complete investigation and report the
actions taken and conclusions reached by the facility within five (5) days of
discovery of the incident.
[7.1.13.10 NMAC - Rp, 7.1.13.11 NMAC,
7/1/14]
7.1.13.11 CONSEQUENCES OF LICENSED HEALTH CARE
FACILITY NONCOMPLIANCE:
A. The
department or other governmental agency having regulatory enforcement authority
over a licensed health care facility may sanction a licensed health care
facility or in accordance with
applicable law if the licensed health care facility fails to report incidents
of abuse, neglect or exploitation or fails to provide or fails to maintain
evidence of an existing incident management system and employee training
documentation as set forth by this rule, fails to take reasonable measures to
protect consumers from abuse, neglect or exploitation, or any other violation
of this rule.
B. Such
sanctions may include revocation or suspension of license, directed plan of
correction, intermediate sanctions or civil monetary penalty up to five
thousand dollars ($5,000) per instance.
C. All confirmed
incident investigations conducted by the department hold the licensed health
care facility responsible for the actions of the employee in their employment
with the following exception: any employee found to have caused the abuse,
neglect or exploitation shall be held accountable independent of the licensed
health care facility when the facility has complied with all requirements of
this rule and the employee acts outside of the provider’s system. The employee
shall be subject to the Employee Abuse Registry Act, or referred to the
appropriate certification or licensing authority and reported to law
enforcement agencies when appropriate.
[7.1.13.11 NMAC - Rp, 7.1.13.12 NMAC,
7/1/14]
7.1.13.12 CONFIDENTIALITY:
All consumer information reviewed or obtained in the course of a survey
or investigation of a licensed health care facility is confidential in
accordance with all applicable federal and state law and regulation. If a
complaint is unsubstantiated, no information regarding the substance of the
complaint or the alleged individual or provider perpetrator may be released
publicly. If a complaint is substantiated, confidential information includes,
but is not limited to: identity of the incident report form reporter if
confidentiality has been requested, personnel records, dates of birth, drivers’
license numbers, social security numbers, personal addresses and telephone
numbers, the licensed health care facility’s internal incident investigations, financial
documents and proprietary business information.
[7.1.13.12 NMAC - Rp, 7.1.13.13 NMAC,
7/1/14]
7.1.13.13 SEVERABILITY: If any provision or application of 7.1.13
NMAC is held invalid, the remainder, or its application to other situations or
persons, shall not be affected.
[7.1.13.13 NMAC - Rp, 7.1.13.14 NMAC,
7/1/14]
HISTORY OF 7.1.13 NMAC:
Pre-NMAC History: None.
History of Repealed Material: 7.14.3 NMAC, Incident Reporting and
Investigation Requirements for Providers of Community Based Services (filed
01/10/03) repealed 02/28/06.
7.1.13
NMAC, Incident Reporting, Intake, Processing and Training Requirements (filed
02/15/06) repealed 07/01/14.
NMAC History:
7.14.3
NMAC, Incident Reporting and Investigation Requirements for Providers of
Community Based Services (filed 01/10/03) was renumbered and replaced by 7.1.13
NMAC, Incident Reporting, Intake, Processing and Training Requirements,
effective 02/28/06.
7.1.13
NMAC, Incident Reporting, Intake, Processing and Training Requirements (filed
02/15/06) was repealed and replaced by 7.1.13 NMAC, Incident Reporting, Intake,
Processing and Training Requirements, effective 07/01/14.
