Report of Events

PURPOSE: This rule prescribes procedures for documenting, reporting, analyzing, and addressing certain events that affect individuals who reside in a community residential program or are receiving day program or specialized services from an agency that is licensed, certified, accredited, in possession of deemed status, is funded by, and/or has a contractual relationship with the Department of Mental Health for the provision of services as required by sections 630.005, 630.020, 630.163, 630.165, 630.167, and 630.655, RSMo. (1) Definitions. The following words and terms, as used in this rule, mean: (A) Administrative agent, an organization and its approved designee(s) authorized by the department as an entry and exit point into the state mental health service delivery system for a geographic service area defined by the department; (B) Affiliate, an organization that is contracted with the department to provide specific community psychiatric rehabilitation (CPR) services in a designated geographic region; (C) Agency, a community residential program/center, day program, group home, outpatient program, and/or specialized services licensed, certified, deemed certified, or deemed licensed by the department, and/or funded by, and/or has a contractual relationship with the department for the provision of services. This does not include entities licensed by the Department of Health and Senior Services under Chapter 198, RSMo, unless the entity is also licensed by the department to serve individuals that have a primary diagnosis of mental illness and/or developmental disability and their services and supports are funded by the department; (D) Customer Information Management, Outcomes, and Reporting, Event Management and Tracking (CIMOR-EMT), system used by the department to collect and analyze relevant data on events that have actual or potential adverse outcomes for individuals served. Data is entered into the system by agency staff or department staff in accordance with established policies and procedures; (E) Deemed status, acknowledges that an agency is monitored and held accountable by a recognized national accrediting body and the department accepts the agency’s verification of good standing with the accrediting body as sufficient to meet the department’s standards of care; (F) Department, the Department of Mental Health, executive agency of Missouri state government comprised of the Division of Behavioral Health (DBH) and Division of Developmental Disabilities (DD) and its regional and district offices; (G) Division of Behavioral Health (DBH), operating division of the department responsible for ensuring prevention, evaluation, treatment, recovery supports, and rehabilitation services are available for individuals and family members experiencing a substance use disorder and/or mental illness; (H) Division of Developmental Disabilities (DD), operating division of the department responsible for supporting the needs of individuals, family members, and caregivers who experience a developmental disability; (I) EMT Community Event Report, form used by community providers for reporting events to the department in accordance with DBH and DD protocol; (J) Guardian, individual who is court appointed to be legally responsible for the care and custody of the individual being served; (K) Individual, a person/consumer/client receiving department-funded services directly from an agency or selfdirected services; (L) Reportable events/categories, events affecting individuals residing in or receiving services from an agency, as defined in subsection (1)(C) of this rule, that meet reporting requirements applicable to DBH or DD; (M) On-call system, procedure in which identified staff in DD are available to receive notification of reportable events requiring immediate notification during non-business hours, a weekend, or holiday; (N) Plan of Action (POA), documents the action to be taken by agency staff to reduce the likelihood an event will recur or to remediate an area found out of compliance. Such action may include, but is not limited to, staff training, improvements to the physical plant, and/or revision of operating procedures; (2) Reporting Requirements. This rule applies to any employee of an agency as defined in subsection (1)(C) of this rule. (A) Agency designee(s) shall ensure events are reported in accordance with protocol established by DD or DBH, as applicable to the individual being served. 1. Event reports involving individuals served by DD shall be submitted via the CIMOR-EMT system in accordance with established protocols. 2. Event reports involving individuals served by DBH shall be submitted to designated DBH staff via the EMT Community Event Report form MO 650-9475, included herein, in accordance with established protocols. A. Administrative agents/affiliates shall be notified of events involving individuals receiving DBH-funded services. The administrative agent/affiliate shall submit event reports to the appropriate DBH regional office staff via the EMT Community Event Report form MO 650-9475, included herein, in accordance with established protocols. (B) Any allegation or suspicion of abuse, neglect, or misuse of funds/property, as defined in 9 CSR 10-5.200, which is reported to or suspected by agency staff must be immediately reported to the applicable division in accordance with procedures described in 9 CSR 10-5.200. (C) Events requiring immediate notification which occur after 5:00 p.m. on a weekday, weekend, or holiday shall be reported as follows: 1. To DBH staff no later than the next business day in a written report utilizing the EMT Community Event Report form MO 650-9475. 2. To DD staff verbally in accordance with the on-call protocol, followed by entry into CIMOR-EMT on the next business day. (D) The parent(s) of a minor or the legal guardian of an individual who is involved in a report of abuse, neglect, and/ or misuse of funds/property shall receive verbal notification from agency staff regarding the details of the event, except the names of any employees or other individuals shall not be revealed. This notification shall occur as soon as possible, but no later than twenty-four (24) hours following the agency’s notification of the alleged event. 1. Email or text communication may be substituted for the verbal notification if the parent/guardian has indicated that is the preferred means of communication. 2. The date and time of parent/guardian notification shall be documented on the event report. 3. Agency staff shall communicate to the parent/guardian that the applicable division (DBH or DD) has been notified of the event. 4. If the parent/guardian is suspected to be involved in the event, notification to the parent/guardian shall be waived. 5. If agency staff are unable to contact the parent/ guardian regarding such an event, efforts to comply must be documented and included in the agency’s event report to the applicable division. (3) Policies and Procedures. Agencies shall maintain and implement written policies and procedures to ensure the event notification, reporting requirements, and division-specific protocol outlined in this rule are followed. (A) The policies and procedures shall clearly indicate the action to be taken by the agency if staff fail to report an event in accordance with the event notification, reporting requirements, and division-specific protocol outlined in this rule. (B) The agency shall ensure all employees, contracted staff, students/interns, and volunteers receive training on the event notification and reporting requirements applicable to their agency, including the agency’s internal policies and procedures. 1. This training shall be included as part of the agency’s orientation process and take place within the first thirty (30) days of employment and annually thereafter. 2. Employees, contracted staff, students/interns, and volunteers who will have direct contact with individuals served must be trained on the event notification, reporting requirements, and division-specific protocol prior to interacting alone with individuals. 3. This training shall include review of the definitions included in 9 CSR 10-5.200 for abuse, neglect, and misuse of funds/property. (4) Plan of Action (POA) and Follow-up. The DBH or DD may request a POA from an agency based on the facts surrounding the event. This POA is subject to approval by the DBH or DD designee, must be carried out as specified, and shall be implemented by the agency in accordance with the approval criteria issued by the applicable division. (A) Corrective measures and action steps to resolve the issue must be documented and maintained by the agency and be available for review by DBH or DD staff or other authorized representatives upon request. (5) Failure to follow these regulations may result in administrative sanctions up to and including contract cancellation or revocation of licensure, certification, or deemed status. AUTHORITY: sections 630.020, 630.165, and 630.655, RSMo 2016, and sections 630.005 and 630.167, RSMo Supp. 2021.* Original rule filed March 1, 2005, effective Oct. 30, 2005. Amended: Filed Aug. 26, 2005, effective Feb. 28, 2006. Amended: Filed March 9, 2022, effective Sept. 30, 2022. *Original authority: 630.005, RSMo 1980, amended 1981, 1982, 1990, 1993, 1995, 1996, 2007, 2011, 2014, 2018; 630.020, RSMo 1980; 630.165, RSMo 1980, amended 1996, 2003, 2007, 2008, 2011, 2014; 630.167, RSMo 1980, amended 1985, 1990, 1993, 1996, 1998, 2003, 2007, 2008, 2011, 2014, 2018; and 630.655, RSMo 1980.