{"ref":"GA-HSP-QA-02","title":"Reports to the Department of Community Health and Internal Investigations","category":"Quality","summary":"Sets out the reports the Agency must make to the Georgia Department of Community Health under Ga. Comp. R. & Regs. 111-8-37-.06: patient incidents (unexpected deaths, rape, assault, abuse, neglect or exploitation, and facility patients missing more than eight hours) within 24 hours or the next business day through the peer review committee; the 45-day internal investigation report; pending involuntary discharges; and disasters and interruptions of vital services, with their 45-day evaluation.","inShort":["Tell a manager at once about any unexpected death, any rape, assault, abuse, neglect or exploitation, or a facility patient who is missing.","These incidents must be reported to the Department within 24 hours or the next business day.","A written internal investigation is completed within 45 days of discovery.","The Department is told of any involuntary discharge no later than the time the patient is told.","Disasters and loss of power, water, gas or phones that disrupt care are reported too."],"primaryCitation":"Ga. Comp. R. & Regs. 111-8-37-.06","citations":["Ga. Comp. R. & Regs. 111-8-37-.06","Ga. Comp. R. & Regs. 111-8-37-.09(1)","Ga. Comp. R. & Regs. 111-8-37-.14(6)(c)","Ga. Comp. R. & Regs. 111-8-37-.11","O.C.G.A. §31-7-130 et seq."],"federalCitations":["42 CFR §418.52(b)(4)(iv)","42 CFR §418.113(b)(1)"],"surveyorAsks":["Show me your last report of a patient incident to the Department, the date of the incident, the date you became aware of it and the date you reported it.","Show me the internal investigation report for that incident. When was it completed, and where is the root cause analysis?"],"forms":[{"ref":"GA-HSP-QA-02-A","title":"Incident Report to the Department: Internal Worksheet"},{"ref":"GA-HSP-QA-02-B","title":"Internal Investigation Report (45-Day)"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (Ga. Comp. R. & Regs. 111-8-37-.06)","5. Patient Incidents That Must Be Reported","6. How a Patient Incident Is Reported","7. Internal Investigation (45 Days)","8. Pending Involuntary Discharge","9. Disasters and Interruption of Vital Services","10. Confidentiality and Department Follow-Up","11. Other Reports Staff Often Confuse With These","12. Responsibilities","13. Records and Compliance Monitoring","14. Staff Training","15. References","16. Related Policies and Forms","17. Approval","18. Revision History"],"version":"1.0","sample":false,"pack":"ga-hospice","state":"Georgia","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}}