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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 1032 (February 24, 2024).

55 Pa. Code § 2390.19. Incident procedures to protect the client.

§ 2390.19. Incident procedures to protect the client.

 (a)  In investigating an incident, the facility shall review and consider the following needs of the affected client:

   (1)  Potential risks.

   (2)  Health care information.

   (3)  Medication history and current medication.

   (4)  Behavioral health history.

   (5)  Incident history.

   (6)  Social needs.

   (7)  Environmental needs.

   (8)  Personal safety.

 (b)  The facility shall monitor a client’s risk for recurring incidents and implement corrective action, as appropriate.

 (c)  The facility shall work cooperatively with the individual plan team to revise the individual plan if indicated by the incident.

 (d)  The facility shall complete the following for each confirmed incident:

   (1)  Analysis to determine the cause of the incident.

   (2)  Corrective action if indicated.

   (3)  A strategy to address the potential risks to the client.

 (e)  The facility shall review and analyze incidents and conduct and document a trend analysis at least every 3 months.

 (f)  The facility shall identify and implement preventive measures to reduce:

   (1)  The number of incidents.

   (2)  The severity of the risks associated with the incident.

   (3)  The likelihood of an incident recurring.

 (g)  The facility shall educate staff persons and the client based on the circumstances of the incident.

 (h)  The facility shall monitor incident data and take actions to mitigate and manage risks.


   The provisions of this §  2390.19 amended under sections 201(2), 403(b), 403.1(a) and (b), Articles IX and X of the Human Services Code (62 P.S. § §  201(2), 403(b), 403.1(a) and (b), 901—922 and 1001—1088); and section 201(2) of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. §  4201(2)).


   The provisions of this §  2390.19 adopted May 9, 1986, effective August 8, 1986, 16 Pa.B. 1693; amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177; amended October 4, 2019, effective in 120 days, 49 Pa.B. 5777. Immediately preceding text appears at serial pages (381394) to (381395).

Cross References

   This section cited in 55 Pa. Code §  6000.312 (relating to no license factors); and 55 Pa. Code §  6000.313 (relating to provisional license factors).

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