1. (a) The provider 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 provider shall review and analyze incidents and conduct and document a trend analysis at least every 3 months.

3. (c) The provider 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 provider shall educate staff persons, others and the individual based on the circumstances of the incident.
5. (e) The provider shall monitor incident data and take actions to mitigate and manage risks.

Cross References

This section cited in 55 Pa. Code § 6100.803 (relating to organized health care delivery system); and 55 Pa. Code § 6100.804 (relating to base-funding).