Section 9. Incident Management System Requirements

A. General: All community-based service providers shall establish and maintain an incident management system, which emphasizes the principles of prevention and staff involvement. The community-based service provider shall ensure that the incident management system policies and procedures requires all employees and volunteers to be competently trained to respond to, report, and preserve evidence related to incidents in a timely and accurate manner. B. Training curriculum: Prior to an employee or volunteer’s initial work with the community-based service provider, all employees and volunteers shall be trained on an applicable written training curriculum including incident policies and procedures for identification, and timely reporting of abuse, neglect, exploitation, suspicious injury, and all deaths as required in Subsection A of 8.370.10.8 NMAC. The trainings shall be reviewed at annual, not to exceed 12-month intervals. The training curriculum as set forth in Subsection C of 8.370.10.9 NMAC may include 8.370.10 NMAC 5 computer-based training. Periodic reviews shall include, at a minimum, review of the written training curriculum and site-specific issues pertaining to the community-based service provider’s facility. Training shall be conducted in a language that is understood by the employee or volunteer. C. Incident management system training curriculum requirements: (1) The community-based service provider shall conduct training or designate a knowledgeable representative to conduct training, in accordance with the written training curriculum provided electronically by the division that includes but is not limited to: (a) an overview of the potential risk of abuse, neglect, or exploitation; (b) informational procedures for properly filing the division's abuse, neglect, and exploitation or report of death form; (c) specific instructions of the employees’ legal responsibility to report an incident of abuse, neglect and exploitation, suspicious injury, and all deaths; (d) specific instructions on how to respond to (a) an overview of the potential risk of abuse, neglect, or exploitation; (b) informational procedures for properly filing the division's abuse, neglect, and exploitation or report of death form; (c) specific instructions of the employees’ legal responsibility to report an incident of abuse, neglect and exploitation, suspicious injury, and all deaths; (d) specific instructions on how to respond to abuse, neglect, or exploitation; (e) emergency action procedures to be followed in the event of an alleged incident or knowledge of abuse, neglect, exploitation, or suspicious injury. (2) All current employees and volunteers shall receive training within 90 days of the effective date of this rule. (3) All new employees and volunteers shall receive training prior to providing services to consumers. D. Training documentation: All community-based service providers shall prepare training documentation for each employee and volunteer to include a signed statement indicating the date, time, and place they received their incident management reporting instruction. The community-based service provider shall maintain documentation of an employee or volunteer's training for a period of at least three years, or six months after termination of an employee's employment or the volunteer’s work. Training curricula shall be kept on the provider premises and made available upon request by the authority. Training documentation shall be made available immediately upon a division representative's request. Failure to provide employee and volunteer training documentation shall subject the community-based service provider to the penalties provided for in this rule. E. Consumer and guardian orientation packet: Consumers, family members, and legal guardians shall be made aware of and have available immediate access to the community-based service provider incident reporting processes sentative's request. Failure to provide employee and volunteer training documentation shall subject the community-based service provider to the penalties provided for in this rule. E. Consumer and guardian orientation packet: Consumers, family members, and legal guardians shall be made aware of and have available immediate access to the community-based service provider incident reporting processes. The community-based service provider shall provide consumers, family members, or legal guardians an orientation packet to include incident management systems policies and procedural information concerning the reporting of abuse, neglect, exploitation, suspicious injury, or death. The community-based service provider shall include a signed statement indicating the date, time, and place they received their orientation packet to be contained in the consumer’s file. The appropriate consumer, family member, or legal guardian shall sign this at the time of orientation. F. Availability of incident management and abuse, neglect, exploitation, suspicious injury, or report of death reporting information: All community-based service providers shall provide written information to be furnished by the division at its website, which states all incident management reporting procedures, including contact numbers and internet addresses. The written information shall be on-site and available to staff. [8.370.10.9 NMAC - N, 07/01/2024] 8.370.10.10 ACCESS AND COOPERATION TO FACILITATE AUTHORITY INCIDENT INVESTIGATIONS: A. The authority will conduct incident investigations of community-based service providers subject to these requirements. These investigations may be either announced or unannounced. B numbers and internet addresses. The written information shall be on-site and available to staff. [8.370.10.9 NMAC - N, 07/01/2024] 8.370.10.10 ACCESS AND COOPERATION TO FACILITATE AUTHORITY INCIDENT INVESTIGATIONS: A. The authority will conduct incident investigations of community-based service providers subject to these requirements. These investigations may be either announced or unannounced. B. All community-based service providers programs shall facilitate immediate physical or in-person access, and assist with scheduling of interviews, by authority personnel investigating incidents to all of the providers: (1) formal and informal records, regardless of media, including but not limited to, financial records, all consumer records, individual service plans, volunteer and personnel records, board and or committee minutes, incident reports, quality assurance activities, client satisfaction surveys, and agency policy and procedures manuals; (2) employees and volunteers with knowledge of the incident; (3) necessary clients currently receiving services, guardians, representatives, and family members with knowledge of the incident; and (4) administrative and service delivery sites. [8.370.10.10 NMAC - N, 07/01/2024] 8.370.10 NMAC 6 8.370.10.11 CONSEQUENCES OF COMMUNITY-BASED SERVICE PROVIDER NON- COMPLIANCE: A. The authority may sanction a community-based service provider in accordance with applicable law if the community-based service provider fails to report incidents of abuse, neglect, exploitation, suspicious injury, or any death; fails to provide or maintain evidence of an existing incident management system and employee and volunteer training documentation as set forth by this rule; for any failure to adequately protect consumers from abuse, neglect or exploitation; or for any other violation of this rule. B -based service provider fails to report incidents of abuse, neglect, exploitation, suspicious injury, or any death; fails to provide or maintain evidence of an existing incident management system and employee and volunteer training documentation as set forth by this rule; for any failure to adequately protect consumers from abuse, neglect or exploitation; or for any other violation of this rule. B. Such sanctions may include a directed plan of correction, intermediate sanctions, or civil monetary penalty up to $5,000 per instance, or high level sanctions up to and including termination or non-renewal of any provider agreement with the authority or other governmental agency. C. All substantiated incident investigations conducted by the authority hold the community-based service provider responsible for the actions of the employee, volunteer, or contractor with the following exception: any employee, volunteer, or contractor found to have caused the abuse, neglect, or exploitation of a consumer shall be found individually responsible independent of the community-based service provider when the community-based service provider has complied with all requirements of this rule, and the employee acts outside of the provider’s system. When this occurs, the individual shall be subject to the Employee Abuse Registry Act, Sections 29-27-1 through 29-27-8 NMSA 1978, or referred to the appropriate professional licensing board and law enforcement where appropriate.