Reporting Requirements

(1) The Facility shall submit to the SOTA all reports resulting from a survey, inspection, or complaint investigation from the DEA, SAMHSA, the Facility’s accrediting organization, and any other applicable agency or organization, either electronically or by mail, within five (5) business days of receiving such documents. (2) The Facility shall report each case of communicable disease to the local county health officer in the manner provided by T.C.A. § 68-5-102 and Division 1200-14 of the Rules of the Tennessee Department of Health. (3) The Facility shall report within twenty-four (24) hours to the Office of Licensure and the Office of the SOTA the abuse of a service recipient, an unexpected occurrence or accident that results in death or serious injury to a service recipient, or any action taken against the Facility by the DEA, accrediting body or other state, local or federal agency. Additionally, the following are examples of events that should be reported: (a) Medication errors that caused or had the potential to cause harm to the service recipient; (b) Criminal acts; (c) Suicide or attempted suicide; (d) Rape; (e) Neglect of a service recipient; (f) Service recipient altercations; (g) Service recipient abuse; MINIMUM PROGRAM REQUIREMENTS FOR NON-RESIDENTIAL CHAPTER 0940-05-42 OPIOD TREATMENT PROGRAM FACILITIES (h) Misappropriation of service recipient funds, including any grant funding, if applicable; (i) Restraint-related incidents; (j) Overdose occurring within the Facility; or (k) Improper disclosure of a service recipient’s protected health information. (4) Specific incidents that might result in a disruption of the delivery of health care services at the Facility shall be reported to the Office of Licensure and the Office of the SOTA within twenty- four (24) hours after the Facility learns of the incident. These specific incidents include the following: (a) Strike by the staff at the Facility; (b) External disaster impacting the Facility; (c) Disruption of any service vital to the continuous, safe operation of the Facility or to the health and safety of its service recipients and personnel; and (d) Fires at the Facility which disrupt the provision of service recipient care services, cause harm to service recipients or staff, or which are reported by the Facility to any entity, including, but not limited to, a fire department or other local emergency services. (5) Within seven (7) days of any event described in Paragraph (3), the Facility shall file a report with the Office of Licensure and the Office of the SOTA on the incident consisting of the following: (a) The actions implemented to prevent the reoccurrence of the event; (b) The time frames for the action(s) to be implemented; (c) The person(s) designated to implement and monitor the action(s); and (d) The strategies for the measurements of effectiveness to be established.