(a) Mental health providers are responsible for compiling and analyzing incident data for reportable incidents, incidents reported to the Office pursuant to section 524.10 of this Part, and patient death, for the purpose of identifying possible patterns and trends and to determine the timeliness, thoroughness, and appropriateness of the provider’s responses.

1. (1) At a minimum, incident data shall be analyzed according to incident type, patient involvement, location, date, and time, and employee involvement.
2. (2) Reviews shall not be considered to be complete until all relevant information, (including final investigation reports and relevant systems analyses), has been gathered, opportunities for improvement have been identified, and, if deemed necessary, plans of correction/prevention have been developed, implemented, and monitored.

3. (3) For investigations of reportable incidents, correction/prevention plans must be documented in accordance with guidelines of the office.

   (b) Incident review committees.

   Each mental health provider shall appoint a standing incident review committee to assure that all reportable incidents, incidents reported to the Office pursuant to section 524.10 of this Part, and patient death, are reviewed and monitored, that all reportable incidents that may adversely affect the care and safety of patients are appropriately addressed, and that preventive and corrective measures are identified, as appropriate.

4. (1) Incident review committees may be organized on a provider-wide, multi-program or program-specific basis, and may have responsibilities other than those related to incident management. The composition of an incident review committee must be such that a free and open exchange of information is ensured, in order to facilitate full and complete investigations. Providers shall maintain current documentation attesting that committee membership at least includes:

   1. (i) members of the governing body of the mental health provider;

   2. (ii) persons identified by the director of such provider, including some members of the following:

      1. (a) direct support staff, which shall mean staff who are involved in the provision of direct care services;
      2. (b) licensed health care practitioners;
      3. (c) service recipients; and
      4. (d) representatives of family, consumer, or advocacy organizations.

5. (2) The director of the mental health provider shall not be a member of the incident review committee. For purposes of this section, director shall mean:

   1. (i) the executive director of a State operated facility; or
   2. (ii) the chief executive director of a licensed provider of mental health services, as designated by the signatory (or his/her successor) of the Prior Approval Review form Part A Acknowledgement submitted in accordance with Part 551 of this Title.
6. (3) The incident review committee shall include a physician on a regular membership or ad hoc basis. The physician shall participate in review of all medically related incidents.
7. (4) The scheduling of incident review committee meetings shall in no way preclude the prompt and thorough review of each incident. Each incident review committee shall meet within 45 days of acceptance of the report by the Justice Center, or sooner should the circumstances so warrant, but no less frequently than on a quarterly basis, to allow for the timely review and closure of incidents.

8. (5) Incident review committees shall take an active role in assuring that:

   1. (i) Incidents are reported, managed, investigated and documented consistent with the provisions of this Part and with the provider’s policies and procedures, and written recommendations are made to the appropriate staff and/or the director of the provider of services to correct, improve or eliminate inconsistencies;
   2. (ii) necessary and appropriate corrective, preventive, and/or disciplinary action is taken to protect persons receiving services from harm and to safeguard against the recurrence of similar incidents;
   3. (iii) if further investigation or if additional corrective, preventive, and/or disciplinary action is necessary, appropriate written recommendations are made to the director of the provider relative to the incident;
   4. (iv) trends in incidents, (e.g., by type, person, site, employee involvement, time, date, circumstances, etc.), are identified, and recommendations are made regarding appropriate corrective, preventive, and/or disciplinary action to the director to safeguard against and reduce such recurring situations or incidents; and
   5. (v) the provider’s reporting and review practices, including the monitoring of the implementation of approved recommendations for corrective and preventive action, are effective.
9. (6) Incident review committee members who may bear some responsibility for an incident shall be excluded from the committee's deliberations regarding that incident.

10. (7) Written minutes of all meetings shall be maintained.

    1. (i) Minutes shall indicate when review of a particular incident has been completed. Review shall be deemed complete when all relevant information, including the final investigative report, has been gathered, opportunities for improvement have been identified, and plans of correction/prevention have been developed and implemented.
    2. (ii) Minutes are to be filed and otherwise maintained in a manner that ensures confidentiality.
11. (8) Reports based on the minutes shall be developed and submitted to the director of the mental health provider, as determined necessary by the committee. Such reports shall include a summary of the committee's discussions, findings and recommendations, as well as follow-up actions taken to assure that all recommended preventive and/or corrective measure(s) are implemented.
12. (9) All members of the incident review committee must be trained in relevant confidentiality laws and regulations.