{"ref":"DC-HSP-QA-02","title":"Incident Reporting, Internal Investigation and Learning From Adverse Events","category":"Quality","summary":"Sets out how staff report incidents inside the Agency, how each incident is triaged, screened for external reporting and investigated, and how the causes are analyzed and turned into preventive actions with feedback and learning across the Agency, as 42 CFR §418.58 requires.","inShort":["If something goes wrong, make the patient safe first and call 911 if needed.","Tell the clinical manager or on-call nurse at once.","If you suspect abuse or neglect, report it to APS or CFSA yourself right away as well.","Fill in an incident report before the end of your shift. Write only the facts.","Do not mention the incident report in the patient’s record.","Reporting is for learning, not blame. No one is disciplined for reporting in good faith."],"primaryCitation":"42 CFR §418.58(a)(2), (c)(2)","citations":["D.C. Code §7-161","DC Health memorandum, Serious Adverse Event Reporting System (August 19, 2026)"],"federalCitations":["42 CFR §418.58(a)(2), (c)(2)","42 CFR §418.52(b)(4)","42 CFR §418.110(p)"],"surveyorAsks":["What do staff do when a patient falls or a medication error happens?","Show me the incident reports for the last quarter and what you learned from them."],"forms":[{"ref":"DC-HSP-QA-02-A","title":"Incident Report"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §418.58(a)(2), (c)(2))","5. What Must Be Reported","6. Reporting Steps","7. Triage and External Reporting Screen","8. Investigation and Analysis","9. Telling the Patient and Family","10. Trending, Feedback and Learning","11. Responsibilities","12. Records and Compliance Monitoring","13. Staff Training","14. References","15. Related Policies and Forms","16. Approval","17. Revision History"],"version":"1.0","sample":false,"pack":"dc-hospice","state":"Washington, DC","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}}