(b) At a minimum, an incident management program must be consistent with Justice Center incident reporting regulations and incorporate the following:

1. (1) identification of staff responsible for administration of the incident management program;
2. (2) provisions for annual review by the governing authority;
3. (3) specific internal recording and reporting procedures applicable to all incidents observed, discovered or alleged;
4. (4) procedures for monitoring overall effectiveness of the incident management program;

5. (5) minimum standards for investigation of incidents observed, discovered or alleged, including, but not limited to:

   1. (i) physical or medical examination, as indicated by circumstances; name of examiner; written findings;
   2. (ii) identification and interviews with any witnesses (interviews conducted separately by qualified, objective persons); written documentation of such interviews;
   3. (iii) review of pertinent physical evidence; documentation (photos, expert assessments) and retention by facility incident review committee, facility executive or other appropriate person;
   4. (iv) documentation of investigative steps taken;
6. (6) procedures for the implementation of corrective action plans if required;
7. (7) establishment of an incident review committee pursuant to subdivision (f) of this section;
8. (8) required periodic training in mandated reporting obligations of custodians and the Justice Center code of conduct, in addition to any other training as may be required by the office and consistent with Justice Center regulations;
9. (9) provision for retention of records, review and release pursuant to Justice Center regulations and section 33.25 of the Mental Hygiene Law.

(e) Upon clearance for employment any custodian must be informed of the service provider’s incident management program, custodian obligations as a mandated reporter, and an original signed attestation by such custodian that they have received and understand such obligations. Custodian attestation to receiving and understanding the code of conduct must be renewed annually.

1. (1) each incident review committee must include members of the governing body of the provider agency and other persons identified by the director, including members from the following: direct support staff, licensed health care practitioners, service recipients and representatives of family, consumer and other advocacy organizations (if appropriate, based on the size of the facility or provider agency, the office may authorize an exemption from this requirement or portions of this requirement upon review of a written request). The executive director of a provider may not serve as an incident review committee member;
2. (2) services not requiring medical staff may substitute a qualified health professional for the medical staff;
3. (3) in a service co-located within a general hospital or a certified hospital for mental illness, or a service that is part of a larger human services agency, the functions of the incident review committee may be performed by a hospital-wide committee or an agency-wide committee, provided a representative from the chemical dependence or compulsive gambling unit serves on the committee and confidentiality is maintained pursuant to 42 CFR part 2, and the functions of the committee meet or exceed the requirements of this Part;
4. (4) members of the committee shall be trained in confidentiality laws and regulations and shall comply with section 74 of the Public Officers Law (Code of Ethics);

5. (5) committee functions and responsibilities. At a minimum, each incident review committee must:

   1. (i) review and evaluate all incidents;
   2. (ii) determine the facts, review and evaluate ongoing practices and procedures in relation to such incidents, and recommend any indicated changes in practices and procedures to improve the provider’s response to all incidents;
   3. (iii) determine whether there are patterns or common causes of incidents and make recommendations for changes to prevent recurrence;
   4. (iv) meet as often as necessary to properly execute its functions, but in no event less than quarterly;
   5. (v) keep written minutes of its deliberations and submit bi-annual reports to the governing authority;
   6. (vi) prepare a summary of incidents reviewed and recommendations made, if any, at each meeting; and
   7. (vii) take any action necessary to follow up on recommendations made;
6. (6) incident review committees are responsible for reviewing individual incidents and incident patterns to determine the timeliness, thoroughness and appropriateness of the program’s response. The committee may make recommendations to the governing body regarding the implementation of any preventive or corrective action;
7. (7) incident review committees are responsible for monitoring the compliance of the program’s incident management practices and the implementation of any corrective action taken by the provider. Any corrective action required must be endorsed, in writing, by the facility director or his/her designee, identify a monitoring date and person responsible for assessing the efficacy of the corrective action;
8. (8) the incident review committee must quarterly compile a collective report of the total number of incidents by type, its findings and recommendation; such reports shall be maintained by the governing authority to be available for inspection or review by the office for purposes of recertification or by the Justice Center for such purposes as it may designate.

(f) Incident review committee.

Each provider’s incident management program must provide for the establishment of an incident review committee. Such committee may also perform other review functions for the facility or service provider, including but not limited to, quality improvement and/or utilization review, however minimum requirements include, but are not limited to: