1. (a) The facility shall complete the following for each confirmed incident:

   1. (1) Analysis to determine the cause of the incident.
   2. (2) Corrective action, if indicated.
   3. (3) A strategy to address the potential risks to the individual.
2. (b) The facility shall review and analyze incidents and conduct and document a trend analysis at least every 3 months.

3. (c) The facility shall identify and implement preventive measures to reduce:

   1. (1) The number of incidents.
   2. (2) The severity of the risks associated with the incident.
   3. (3) The likelihood of an incident recurring.
4. (d) The facility shall educate staff persons and the individual based on the circumstances of the incident.
5. (e) The facility shall monitor incident data and take actions to mitigate and manage risks.

Authority

The provisions of this § 2380.19 amended under sections 201(2), 403(b), 403.1(a) and (b), 911 and 1021 of the Human Services Code (62 P.S. § § 201(2), 403(b), 403.1(a) and (b), 911 and 1021); and section 201(2) of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § 4201(2)).

Source

The provisions of this § 2380.19 adopted December 29, 1978, effective December 30, 1978, 8 Pa.B. 3820; amended January 15, 1993, effective January 16, 1993, 23 Pa.B. 343; amended October 4, 2019, effective in 120 days, 49 Pa.B. 5777. Immediately preceding text appears at serial page (381386).