Incident Management and Reports to Outside Agencies
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.
- Policy number
- CA-HSP-QA-02
- Version
- 1.0
- Main rule
- 22 CCR §74808(e)(8)
- Library
- California hospice · 60 policies
- Category
- Quality
- Sections
- 17
In short
- 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.
What's inside
17 sections. The full text comes with the One-time Policy Pack.
- 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
An inspector may ask
- 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.
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