(b) At a minimum, incident management programs shall consist of the following components:

1. (1) Organization and administration. Mental health providers shall identify staff responsible for the overall operation of the incident management program, and shall train staff regarding their related roles and responsibilities.

2. (2) Incident management plan. Mental health providers shall develop and implement a written incident management plan, which shall include the following:

   1. (i) the goals and objectives of the incident management program; and

   2. (ii) the policies and procedures for the operation of the incident management program which address, at a minimum, the following:

      1. (a) identification, documentation, reporting and investigation of incidents;
      2. (b) review of individual incidents to identify appropriate preventive or corrective action;
      3. (c) review of the facts, circumstances, processes, systems, and areas of risk that contributed to an incident, as well as opportunities for performance improvement;
      4. (d) identification and review of incident patterns and trends; and
      5. (e) monitoring of incident management practices and developing proactive strategies for risk reduction, error prevention, and performance improvement.
3. (3) Monitoring. Programs shall ensure that appropriate mechanisms exist for monitoring the overall effectiveness of the incident management program.