Recovery Services Incident Reporting Guidance

The purpose of this guidance is to inform OASAS Recovery Support Services of the requirement to have an incident management process that ensures the safe, quality provision of care in all recovery supports. This guidance applies to any Recovery Support Service which is funded, operated, licensed, or certified by the Office.

The purpose of an incident management process is to ensure a comprehensive strategy for:

1. identifying, documenting, reporting, and investigating incidents in a timely basis;
2. identifying incident patterns from the compilation and analysis of incident data;
3. reviewing incidents and/or patterns to identify preventive or corrective action;
4. implementing preventive and corrective action plans;
5. monitoring incident management practices; and
6. reporting, investigating, and responding to incidents in coordination with the Office.

“Incident” is an event, accident, or injury during the conduct of any Recovery Support Service activity which involves a participant, support staff, volunteers, peers, or damage to the property in which the service operates. This event has, or may have, an adverse or endangering effect on the life, health, or welfare of participants, support staff, volunteers, or peers and is required to be reported, investigated, and reviewed by OASAS.

“Incident Management Process” is a comprehensive plan developed and maintained by Recovery Support Services. This includes specifications for the identification, investigation, reporting, and appropriate response to all incidents and review by the Recovery Support Service’s Incident Review Committee (IRC).

“Incident Review Committee” is a committee required as part of the Incident Management Process.

“Mandated Reporter” is a staff, employee, manager, volunteer, or peer who is required to report incidents involving participants.

“Participant” is a person who receives or has received services from an OASAS Recovery Support Service. In residential recovery settings, participants may be referred to as residents.

“Participant records” are documented information or participant information files concerning or related to a participant receiving services from a Recovery Support Service.

“Recovery Support Service” is a physical location or program in which recovery services are provided and which is certified, licensed, funded, or operated by OASAS.

“Staff” is an employee, manager, volunteer, or peer who provides recovery support services to participants.

“Subject of the report” is a support staff, employee, manager, volunteer, peer, or participant who is reported to have committed an alleged incident.

1. The governing authority of every physical location or provider agency certified, licensed, funded, or operated by the Office must establish and maintain written policies and procedures constituting an incident management process for responding to, reporting, investigating, and evaluating incidents. All incident management processes are subject to review by the Office and its guidance.
2. At a minimum, an incident management process must be consistent with this guidance and incorporate the following:
   1. identification of staff responsible for administration of the incident management process;
   2. provisions for annual review by the governing authority;
   3. specific internal documenting and reporting procedures applicable to all incidents observed, discovered, or alleged, including incident reports, investigation summary reports, and incident logs;
   4. procedures for monitoring overall effectiveness of the incident management process;
   5. minimum standards for investigation of incidents observed, discovered, or alleged, including, but not limited to:
      1. review of medical and hospital records, name of provider or medical facility; written findings; if applicable;
      2. identification and interviews with any witnesses; Interviews shall be conducted and documented by objective persons not directly involved in the incident;
      3. review of pertinent physical evidence, including documentation, photos, or assessments, and their preservation by recovery support service’s Incident Review Committee, recovery support service executive, or other appropriate person;
      4. documentation of investigative steps taken; and
      5. submission of investigation summary report.
   6. procedures for the implementation of corrective action plans if required;
   7. establishment of an Incident Review Committee according to section (g) of this guidance;
   8. required periodic training of staff in mandated reporting obligations, confidentiality, and incident management as may be required by the Office; and
   9. provision for preservation of participant records, review, and release to the Office.
3. Upon admission to a recovery support service, participants must be informed that a recovery support service maintains an incident management process.
4. During the onboarding process, staff, employees, managers, peers, and volunteers must be informed of the recovery support service’s incident management process and staff obligations as mandated reporters. Additionally, an attestation must be signed by staff, employees, managers, peers, and volunteers, acknowledging that they have received and understand such obligations.
5. During onboarding and on an annual basis thereafter, staff, employees, managers, peers, and volunteers must sign an attestation of receiving and understanding the staff ethical considerations document.
6. During onboarding and on an annual basis thereafter, staff, employees, managers, peers, and volunteers must complete training on confidentiality practices (42 CFR). Recovery support service must maintain training logs of staff completing the trainings. Providers should confer with their individual legal counsels in regard to their internal confidentiality policy. Free 42 CFR training can be accessed if needed online.
7. Incident Review Committee. Each provider’s incident management process must provide for the establishment of an Incident Review Committee. The minimum requirements include, but are not limited to:
   1. Each Incident Review Committee must include members of the governing body of the recovery support service and other persons identified by the administrator(s), including members from the following groups: direct support staff, participants, and representatives from family, consumer, and other advocacy organizations. Members must be objective and should be excluded from committee review of incidents in which they are directly involved.
   2. Members of the committee shall be trained in confidentiality (42 CFR Part 2), regulations, and applicable guidance.
   3. Committee functions and responsibilities. At a minimum, each Incident Review Committee must:
      1. review and evaluate all incidents;
      2. determine the facts, review, and evaluate ongoing practices and procedures in relation to such incidents, and recommend any indicated changes in policies and procedures to improve the provider’s response to all incidents;
      3. determine whether there are patterns, trends, or common causes of incidents, and make recommendations for changes to prevent recurrence;
      4. meet as often as necessary to properly execute its functions, and meetings must occur on a regular schedule;
      5. keep written minutes of its deliberations and submit bi-annual reports to the governing authority;
      6. prepare a summary of incidents reviewed and recommendations made, if any, at each meeting; and
      7. take any action necessary to follow up on recommendations made.
   4. Incident Review Committees are responsible for reviewing individual incidents and incident patterns to determine the appropriateness of the recovery support service’s response. The committee may make recommendations to the governing body regarding the implementation of any preventive or corrective action.
   5. Incident Review Committees are responsible for monitoring the compliance of the recovery support service’s incident management practices and the implementation of any corrective action taken by the provider.
   6. The Incident Review Committee must annually compile an aggregated report consisting of the total number of incidents, findings, and recommendations; such reports shall be maintained by the governing authority to be available for inspection or review by the Office for purposes of recertification or such purposes as it may designate.

1. All recovery support services certified, licensed, funded, or operated by the Office shall report incidents to the OASAS Bureau of Patient Advocacy. Use objective language. Avoid interpretation and opinion in the description. Be as concrete as possible in the description of what occurred or what was alleged to have occurred. The initial report of an incident in a recovery support service, at a minimum must contain:
   1. The exact date and time of the incident if known; and
   2. A description of the incident, including location, and actions taken in response to it; and
   3. The name(s), address(es), and telephone number(s) of the victim(s), witness(es), and any other persons involved; and
   4. The presence of injuries, if any, and first aid provided to address such injuries; and
   5. The immediate precautions put in place by staff, employees, managers, volunteers, and peers because of this incident, if applicable.
2. Once the Recovery Support Service has informed Patient Advocacy of the incident via submission of the incident report, the staff responsible for administration of the incident management process will begin their investigation process and complete an Investigation Summary Report. This process will include:
   1. Review the Incident Report to determine the evidence to gather and the interviews to conduct.
   2. Conduct investigation of the incident, including collection of evidence, documentation, and facilitate interviews of all involved individuals. List all sources of evidence gathered and reviewed.
   3. Establish Findings and Conclusions based on a summary of evidence collected.
   4. Establish and document Corrective Actions recommended based on the Findings and Conclusions.
   5. Submit the final Investigation Summary Report with all supporting documentation and evidence to Patient Advocacy for review and further discussion.
3. After submission of the Investigation Summary Report, the staff responsible for the administration of the incident management process will maintain the investigation record to present at the next IRC Meeting.
4. If the IRC makes any additional findings or recommendations, the staff responsible for the incident management process will provide Patient Advocacy with the updated findings or recommendations and submit all applicable documentation.
   1. IRC is responsible for reviewing and ensuring that all corrective actions are documented and implemented.

1. Subject to the provisions of 42 CFR Part 2 or confidentiality practices determined by individual legal counsel, in addition to any other notice provisions required in this guidance, notification of incidents involving a participant must be made by staff to the participant’s family, significant other, or designated emergency contact if applicable consents were signed upon admission.
2. If it appears that a crime may have been committed involving a staff or participant, the recovery support service must immediately make such reports as are necessary to provide notification to the appropriate law enforcement agency of the incident. A recovery support service may disclose participant-identifying information to the appropriate law enforcement agency only when such disclosure:
   1. is directly related to a participant’s commission of a crime on the premises of the recovery support service or a threat to commit such a crime; and
   2. is limited to the circumstances of the incident, including the status of the individual committing or threatening to commit the crime, and such individual’s name and address.
3. In the event of a participant’s death in a recovery support service under any circumstances, or within 30 days of such participant’s discharge, immediate notification must be made to the Bureau of Patient Advocacy.
4. In addition to reporting requirements, specific to recovery residences, in the case of a missing participant, the recovery support service’s incident report is required to indicate that the appropriate supervisory staff member was notified immediately. Upon discovery of a missing participant, a diligent search must be made by staff of the physical plant, grounds, and surroundings for the missing participant. These notifications and practices should be reflected in the policies and procedures of the recovery support service. Telephone inquiries should be made (and documented) to the participant’s home (if their primary residence is not the recovery support service), emergency contacts (if applicable), or any other appropriate location, provided such calls are made in such manner so as not to violate confidentiality requirements of 42 CFR Part 2. Incident reports of a missing participant must state the efforts made to locate the participant as well as the outcome of such efforts.
5. If a manager or staff holding a leadership position of a recovery support service is alleged to have committed or to be directly involved in an incident, staff will not be required to submit an incident report to the recovery support service leadership. In this case, staff members must report such allegations directly to OASAS Bureau of Patient Advocacy.

A copy of each incident report including identifying information must be kept on file at the recovery support service for a minimum of six (6) years and may be subject to inspection and review by the Office.

Copies of the minutes and summaries of the Incident Review Committee must be kept on file at the recovery support service for a minimum of six (6) years and may be subject to inspection and review by the Office.

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