PURPOSE: This rule prescribes procedures for documenting, reporting, analyzing and addressing certain events that affect individuals in residential facilities, day programs or specialized services that are licensed, certified or funded by the Department of Mental Health as required by sections 630.005, 630.020, 630.165, 630.167 and 630.655, RSMo.

1. (1) The following words and terms, as used in this rule, mean:

   1. (A) Consumer, individual receiving department funded or contracted services directly from any program or facility;
   2. (B) Corrective Action Plan, the document a provider submits to the department in response to the results of an event or events which outlines those measures that are intended to reduce the likelihood that the event(s) will recur or to remediate a deficiency. Such actions include but are not limited to: removal of an individual receiving services or staff from a provider; staff training; improvements in the physical plant; revision of operating procedures;
   3. (C) Department, the Department of Mental Health’s local regional center, district administrator, or supported community living office, depending on the division providing service;
   4. (D) Guardian, individual who is legally responsible for the care and custody of the consumer;
   5. (E) “On call” system, procedure of the specific regional department personnel being available to receive notification of events during nonbusiness hours. A telephone number is provided to verbally relay this information to the individual representing the specific region and division providing service;

   6. (F) Provider—

      1. 1. A residential facility, day program or

specialized service that is licensed, certified or funded by the Department of Mental Health;

1. 2. Provider does not include facilities

licensed by the Department of Health and Senior Services under Chapter 198, RSMo unless the facility is also licensed by the Department of Mental Health. In this case this rule applies only to consumers that have a primary diagnosis of mental illness and whose board and care are funded by the Department of Mental Health.

1. 3. Duties of the provider under this rule

are the responsibility of the chief administrative officer of the residential facility, day program or specialized service, or his/her designee;

1. (G) Reportable events, those specific incidents and medication errors identified on the applicable department report form dependent on the division providing service to the consumer; and
2. (H) Report form, Department of Mental Health form identifying reportable events and the timelines for reporting such events to the department. The form is used for data entry into the department Incident and Investigation Tracking System for statewide data collection. This form is identified as DMH- 9719A (Divisions of Alcohol and Drug Abuse and Comprehensive Psychiatric Services) or DMH-9719B (Division of Mental Retardation/Developmental Disabilities), dependent on department division of service, which is included herein.

1. (2) This section applies to event notification and reporting requirements for employees of providers, as defined under section 630.005, RSMo. Facilities, programs and services that are operated by the Department of Mental Health are regulated by the department’s operating regulations and are not included in this definition, because this rule does not apply to Department of Mental Health operated facilities.

   1. (A) Providers must maintain written policies requiring their employees to report events under this regulation and those events identified in 9 CSR 10-5.200. The policies must make clear that administrative or disciplinary sanctions may result from failure to report. Providers must ensure that their employees and those who support the agency are educated about the department’s notification and reporting requirements.

   2. (B) It is the responsibility of the provider to—

      1. 1. Notify the department with a written

or verbal report of all events reportable under this regulation involving consumers as identified on the report form. For those events requiring immediate notification, if a verbal report, it will be followed up in writing on the report form and faxed or otherwise transmitted to arrive within one (1) business day to the appropriate department office. All other events not requiring immediate notification shall be provided in writing on the report form in the time frame specified on the report form.

1. 2. Notify the department using the

department’s “on call” system after 5:00 p.m. or on weekends/holidays for those events on the report form requiring immediate department notification, and any event resulting in extensive property damage or major disruption of the program or service the consumer receives; and

1. 3. Within twenty-four (24) hours of

knowledge of an event that requires immediate department notification, verbally notify the legal guardian or parent (if consumer is a minor) of the specifics regarding the event. The provider shall also communicate that the event has been reported to the department. The only exception to this verbal notification 9 CSR 10-5

is if the parent(s) or legal guardian is the suspected primary person involved that forms the basis for the reported event. If the provider is unable to verbally contact the guardian/parent, the provider shall document on the report form all efforts made to comply.

1. (3) The provider shall ensure that patterns and trends of reportable events, specific to a consumer, are included and addressed in the consumer’s personal/treatment plan upon approval by the planning team. To the extent that specific consumer issues are identified, the department staff may meet with the provider to discuss action steps to address and resolve issues, including submission of corrective action plans.
2. (4) The department may request a corrective action plan be provided by the provider based on the facts surrounding the event. This plan is subject to approval by the department within a time frame specified by the department. This plan must be carried out as specified.
3. (5) Programs licensed or certified by the Department of Mental Health must maintain internal records of similar events or information for individuals who do not receive department funded or contracted services, for purposes of quality review to assure that problems are identified and resolved. Nonidentifying event records or non-identifying analysis of these events must be available for review by the department as needed for monitoring or licensure/certification activities. This section does not apply to facilities licensed under Chapter 198, RSMo.
4. (6) Failure to follow the above referenced regulations may result in administrative sanctions up to and including contract cancellation or licensure/certification revocation. AUTHORITY: sections 630.005, 630.020 and 630.655, RSMo 2000 and 630.165 and 630.167, RSMo Supp. 2004.* Original rule filed March 1, 2005, effective Oct. 30, 2005. Amended: Filed Aug. 26, 2005, effective Feb. 28, 2006.

*Original authority: 630.005, RSMo 1980, amended 1981, 1982, 1990, 1993, 1995, 1996; 630.020, RSMo 1980; 630.165, RSMo 1980, amended 1996, 2003; 630.167, RSMo 1980, amended 1985, 1990, 1993, 1996, 1998, 2003; and 630.655, RSMo 1980.