{"ref":"CA-HSP-QA-02","title":"Incident Management and Reports to Outside Agencies","category":"Quality","summary":"Sets one internal process for reporting, reviewing and learning from incidents, and a single table of the outside reports that California and federal law require, each with its own clock: abuse reports (immediately, with written follow-up), verified violations (5 working days), privacy breaches (15 business days), early destruction of records (24 hours), outbreaks, serious employee injuries to Cal/OSHA (within 8 hours), and others. California has no general incident-reporting rule for hospices, but CDPH may inspect the Agency's incident reports.","inShort":["If something goes wrong, make the person safe first and call 911 in an emergency.","Call the on-call nurse or your supervisor right away, then complete an incident report before the end of your shift.","Write facts only in the patient's record, and do not mention the incident report there.","If you suspect abuse, make your own report to Adult Protective Services, law enforcement or child protective services. Telling your supervisor is not enough.","A staff member's serious work injury must be reported to Cal/OSHA within 8 hours, so tell the Administrator at once."],"primaryCitation":"22 CCR §74808(e)(8)","citations":["22 CCR §74808(e)(8)","22 CCR §74888(i)","22 CCR §74896(n)","22 CCR §74880(d)(4)(B)(iv), (C)","22 CCR §74868(h)","Cal. Health & Safety Code §1280.15","Cal. Welf. & Inst. Code §15630","Cal. Penal Code §11166","8 CCR §342","8 CCR §3342(d)","22 CCR §87633(g)"],"federalCitations":["42 CFR §418.52(b)(4)","42 CFR §418.58(a)(2), (c)(2)","42 CFR §418.112(c)(8)"],"surveyorAsks":["Show me your incident reports for the last quarter and what you did about them.","A nurse finds a patient with a bruise no one can explain. Walk me through what happens next."],"forms":[{"ref":"CA-HSP-QA-02-A","title":"Incident Report"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (22 CCR §74808(e)(8))","5. What Staff Report Inside the Agency","6. Procedure","7. Reports Outside the Agency","8. Investigation and Corrective Action","9. Confidentiality of Incident Reports","10. Responsibilities","11. Records and Compliance Monitoring","12. Staff Training","13. References","14. Related Policies and Forms","15. Approval","16. Revision History"],"version":"1.0","sample":false,"pack":"ca-hospice","state":"California","service":"Hospice","guides":[{"path":"/guides/hospice-policies/","h1":"What policies are required for hospice?"},{"path":"/guides/hospice-conditions-of-participation/","h1":"Hospice Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}