September 23, 2013 Presentation to the Conference of Local Mental

Hygiene Directors

Justice Center Legislation Resulted in revisions to OMH 524 Incident

Management Regulations—Emergency Regs expiring Sept 25, will be extended another 90 days

Please see the OMH Division Of Quality Management Website for a full description of all the information presented today

http://omh.ny.gov/omhweb/dqm/jc/index.html

Changes in these Areas: Code of Conduct and Mandated Reporter

Requirements 24/7 Availability of Administrative Staff to Ensure

Safety OMH Incident Reporting Process Criminal Background Checks (CBC), Staff Exclusion

List (SEL) and Statewide Central Register (SCR) How Investigations are Completed Death Reporting Incident Review Committee Composition

Code of Conduct All employees in OMH licensed facilities need to read

a Code of Conduct and attest that they have read it and that they understand it.

This form should be kept on file. OMH Licensing staff will verify that these attestations

have been completed by checking files on future licensing visits.

Mandated Reporter All employees (Extensive list)should read the

mandated reporter communication memo from the Justice Center

It is not a requirement for non-OMH employees to

attest by signing a form that they have read the Mandated Reporter information.

24/7 Safety Assurances It is now necessary for all providers to furnish OMH

with the name and cell phone number for an administrator who will be on duty after business hours

In the event that an incident of abuse or neglect is called in during the night, OMH will need to contact the Administrator on Duty in order to ensure that all proper safety precautions have been taken

Changes to the Incident Reporting Process

The new OMH 524 regulations have changed the way incidents are reported into NIMRS and also the way incidents are defined. The OMH website has a crosswalk of new vs. old definitions

All “Reportable Incidents” must now be called into the VPCR before you enter them in NIMRS.

You can either call 1-855-373-2122 or submit the web form: https://vpcr.justicecenter.ny.gov/WI/

When calling in, use the 4 digit OMH Facility code (first 4 of the op cert and OMH PCS Survey code)

The Justice Center will process your initial report and transfer it into NIMRS

Significant Incidents must be investigated and closed in NIMRS. Findings/Conclusions are transferred back to the JC

How Investigations are Conducted The Justice Center will determine which incidents it will

investigate and which will be delegated to OMH. OMH will determine whether we will investigate or if we will delegate to your organization.

OMH conducted regional investigation training sessions throughout the Summer, including 2 in NY City. Additional training sessions are planned.

Once the investigation, review, recommendations and conclusions are completed, provider agencies will need to complete a report and close the incident.

If you are delegated to complete an investigation by OMH, all investigative material must be transmitted to OMH within 45 days of acceptance.

Things to Remember Regarding the Investigation Process All materials must be submitted via encrypted files to

OMH Central Office. See August 29 memo from MLF If OMH has delegated the investigation to your

agency, your agency’s investigator must request that the Justice Center conduct a search in the Statewide Central Register (SCR) for any known subjects/suspects in the case. The JC has created a SCR search specific e-mail box for submitting these requests. See August 29 memo

Notifications As required by the Justice Center, the subject(s) of an

allegation of abuse/neglect must be notified that an investigation is being conducted unless notifying the subject would impede the investigation. (see Aug 7 MLF letter)

The Justice Center also requires OMH and our providers to notify vulnerable persons and their personal representatives when an allegation of abuse or neglect involving the vulnerable person is reported to the JC. (MHL 33.23 Jonathan’s Law Notifications must also be adhered to)

Incident Review Committee Composition Committee membership must at least include:

Members of the governing body of the mental health provider Persons identified by the provider’s director including some

of the following: Direct Support Staff Licensed health care practitioners Service recipients And representatives of family, consumer and other advocacy

organizations The Provider’s Director shall not be a member of the committee And must include a physician (either as a regular participant or ad

hoc to review medically related incidents.

IRC—Interim Guidance Nothing in the PPSNA legislation requires providers to

choose members external to the organization. If providers have employees that could serve as representatives of family, consumer or advocacy organizations (peer advocates)those persons could be used to meet requirements.

If external members are chosen: HIPAA and the NYS MHL (Confidentiality) must be adhered

to Use only de-identified information in the discussions Have everyone sign a pledge of confidentiality Get consents

Reporting of Deaths The Justice Center provides information on death reporting at

the following link: http://www.justicecenter.ny.gov/investigations-

prosecution/vpcr/report-death/guidance Programs are required to report the death upon discovery and in

no event later than 24 hours after discovery. Deaths must be called in to the VPCR Death Reporting Line at 1-855-373-2124 and the QCC-100 form fields must be completed in NIMRS.

Agencies need to complete their own investigation into the circumstances surrounding the death (do not wait for the Justice Center to do so)

If there is any reason to suspect abuse or neglect in the death, then a separate report needs to be made to the VPCR at 855-373-2122.

Criminal Background Check, Staff Exclusion List and Statewide Central Register Article 31 inpatient units in Article 28 hospitals are exempt from

the criminal history background check process. This exemption covers providers included on the hospital’s

Article 28 operating certificate; outpatient clinics, part-time or extension clinics, so if affiliated as above, you are exempt from this requirement. Otherwise, you must comply.

Even though programs may be excluded from the CBC process, as licensed mental health providers, they must still submit a request to the Justice Center for a review of the Staff Exclusion List.

In addition, they will also be required to check the Statewide Central Register (SCR).

Interim Process for Provider Staff Exclusion List (SEL) Checks The JC responded to feedback it received from

providers and developed an interim process for checking the SEL. Visit www.justicecenter.ny.gov and click on the red banner at the top, print and save a copy of the dated Interim Request for Staff Exclusion List Check page along with the employment application for each applicant for whom an agency is mandated to conduct an SEL check. This document must be available for OMH auditing staff during licensing visits.

Statewide Central Register (SCR) OCFS operates the SCR. OMH does not issue resource ID

numbers (RID#) nor do we provide access to the SCR. An agency that currently has access to the SCR and has previously obtained clearances on staff from any of their programs may continue to seek clearances for any new staff.

An agency that has not previously had authorization to access the SCR must first obtain a RID # from OCFS. Basic identifying information (name, address, licensing authority, scanned copy of the op cert must be submitted electronically to ocfs.sm.conn_app@ocfs.ny.gov

Once the agency has a RID#, they must contact OCFS at 518-474-5297 to request an application packet in order to obtain SCR clearances. Once approved, a password and information on how to proceed with actual clearances will be provided.

How’s It Going? CHALLENGING Major Issues:

Confusing Regulatory Advice—OMH vs NYJC Intense Volume--2-3 times the normal volume on abuse

allegation and significant incidents Data Issues—Mis-Classified, Mis-channeled incidents

(177 for the month of August) Length of time it takes for NYJC investigators to arrive (results in employees out on leave long periods)

Case Study OMH Facility Individual hired with a criminal history 10+ yrs ago He was honest about background and fingerprint report

verified his statement Individual began as a new employee on orientation status Still on orientation status, about 4 weeks in, performance

issues were noted Supervisor was advised by facility personnel officer that per

Civil Service Policy, probationary period is 8 weeks. Incident occurred, two mandated reporters called it into

JC. Facility began investigation. Employee was sent home (on a Friday)

Continued When employee returned to work on the following

Monday, he was asked to resign and he complied JC investigated and substantiated the allegation Former Employee arrested

What We Learned Should we have hired him with a criminal background?

Section 753 of the Correction Law (23-A) (specific duties, bearing of offense on fitness to perform, amount of time that elapsed since the offense, age at occurrence, information provided by the person about his/her offense

Should we have terminated sooner? As the individual was a MHTA, there is a special provision in

Civil Service law (not widely promulgated) that allows facilities to terminate after only 4 weeks of probation

The individual could have been re-assigned to non patient care duties when the first performance issues were noted

This information has been provided to OMH facilities

Resources Marcia.Fazio@omh.ny.gov General ?/Concerns Jack.Smitka@omh.ny.gov Risk Management Mark.Stevens@omh.ny.gov NIMRS Julie.Rodak@omh.ny.gov Regulations