September 23, 2013

Presentation to the Conference of Local MentalHygiene Directors

Justice Center Legislation Resulted in revisions to OMH 524 Incident

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

Please see the OMH Division Of Quality ManagementWebsite for a full description of all the informationpresented 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 EnsureSafety

OMH Incident Reporting Process

Criminal Background Checks (CBC), Staff ExclusionList (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 andthat they understand it.

This form should be kept on file.

OMH Licensing staff will verify that these attestationshave been completed by checking files on futurelicensing visits.

Mandated Reporter All employees (Extensive list)should read the

mandated reporter communication memo from theJustice Center

It is not a requirement for non-OMH employees toattest by signing a form that they have read theMandated Reporter information.

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

with the name and cell phone number for anadministrator who will be on duty after businesshours

In the event that an incident of abuse or neglect iscalled in during the night, OMH will need to contactthe Administrator on Duty in order to ensure that allproper safety precautions have been taken

Changes to the Incident ReportingProcess

The new OMH 524 regulations have changed the way incidentsare 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 VPCRbefore 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 theop cert and OMH PCS Survey code)

The Justice Center will process your initial report and transfer itinto 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 willdetermine whether we will investigate or if we will delegateto your organization.

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

Once the investigation, review, recommendations andconclusions are completed, provider agencies will need tocomplete a report and close the incident.

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

Things to Remember Regarding theInvestigation 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 youragency, your agency’s investigator must request thatthe Justice Center conduct a search in the StatewideCentral Register (SCR) for any knownsubjects/suspects in the case. The JC has created a SCRsearch specific e-mail box for submitting theserequests. See August 29 memo

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

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

The Justice Center also requires OMH and ourproviders to notify vulnerable persons and theirpersonal representatives when an allegation of abuseor neglect involving the vulnerable person is reportedto the JC. (MHL 33.23 Jonathan’s Law Notificationsmust also be adhered to)

Incident Review CommitteeComposition Committee membership must at least include:

Members of the governing body of the mental health provider

Persons identified by the provider’s director including someof the following:

Direct Support Staff

Licensed health care practitioners

Service recipients

And representatives of family, consumer and other advocacyorganizations

The Provider’s Director shall not be a member of the committee

And must include a physician (either as a regular participant or adhoc to review medically related incidents.

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

choose members external to the organization. If providershave employees that could serve as representatives offamily, consumer or advocacy organizations (peeradvocates)those persons could be used to meetrequirements.

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 becalled in to the VPCR Death Reporting Line at 1-855-373-2124and the QCC-100 form fields must be completed in NIMRS.

Agencies need to complete their own investigation into thecircumstances surrounding the death (do not wait for the JusticeCenter 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, StaffExclusion List and StatewideCentral 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’sArticle 28 operating certificate; outpatient clinics, part-time orextension clinics, so if affiliated as above, you are exempt fromthis requirement. Otherwise, you must comply.

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

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

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

providers and developed an interim process forchecking the SEL. Visit www.justicecenter.ny.gov andclick on the red banner at the top, print and save acopy of the dated Interim Request for Staff ExclusionList Check page along with the employmentapplication for each applicant for whom an agency ismandated to conduct an SEL check. This documentmust be available for OMH auditing staff duringlicensing 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 agencythat currently has access to the SCR and has previously obtainedclearances on staff from any of their programs may continue toseek clearances for any new staff.

An agency that has not previously had authorization to accessthe SCR must first obtain a RID # from OCFS. Basic identifyinginformation (name, address, licensing authority, scanned copy ofthe op cert must be submitted electronically toocfs.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 SCRclearances. Once approved, a password and information on howto 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 abuseallegation 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 thatelapsed since the offense, age at occurrence, informationprovided 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 allowsfacilities to terminate after only 4 weeks of probation

The individual could have been re-assigned to non patientcare 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