Incident Reporting System

October 4, 2011

DAL: DRS-NH 11-12 - Incident Reporting System

Dear Nursing Home Administrators:

The Division of Residential Services introduces a new electronic Incident Reporting Form, which will allow nursing homes to report their incidents through the Health Commerce System (HCS). The new electronic Incident Reporting Form will replace the previous method of reporting incidents occurring at the nursing home using the nursing home hotline. Facilities will be required to report their incidents effective October 17, 2011 using the new Incident Reporting Form available on the HCS.

Federal regulations (42 CFR 483.13), and state regulations (10NYCRR 415.4) require the reporting of alleged violations of abuse, mistreatment and neglect, including injuries of unknown origin, immediately to the facility administrator and in accordance with state law, to the Department of Health. In addition, Federal regulations require that alleged violations of misappropriation of resident property be reported. CMS has defined 'immediately' as, "as soon as possible, but not to exceed 24 hours after the discovery of the incident". NYS Public Health Law (PHL) Section 2803-d requires the reporting of abuse, mistreatment or neglect immediately to the Department upon having "reasonable cause" to believe that abuse, neglect, or mistreatment has occurred. Department regulations at section 81.1(d) (10NYCRR section 81.1(d)) defines "reasonable cause" to mean that upon a review of the circumstances, there is sufficient evidence for a prudent person to believe that physical abuse, mistreatment or neglect has occurred.

Federal and State regulations (42 CFR 483.10(f) and 42 CFR 483.13(c) and 10NYCRR 415.4(b)(2)(3)(4), 415.26(b)(6)) require that providers investigate incidents and complaints. The results of an investigation of abuse, mistreatment, neglect or misappropriation of resident property must be reported both to the administrator (or designees) and to other officials (including the Department of Health) within 5 working days of the incident (42CFR 483.13(c)(4)). An allegation, as previously stated, must be reported immediately to the Department when meeting the reasonable cause standard.

The Department has provided an Incident Reporting Manual to further clarify the reporting requirements, and help ensure that facilities are only reporting incidents required under State and Federal regulations. The manual provides a list of reportable incidents that shall be reported via the HCS. The Department's requirements for reporting incidents are consistent with past reporting requirements.

A Power Point presentation has been prepared to train nursing home employees about the process for investigating incidents, and what constitutes a reportable incident. The Power Point presentation will guide providers on what to report, the information that needs to be gathered, and how to report facility reported incidents.

The Incident Reporting Manual, Power Point Presentation, and Form Instructions can be found below the link to this Dear Administrator Letter. Thank you for your cooperation in working collaboratively with the Department to implement the new incident reporting process.


Jacqueline Pappalardi, Director
Division of Residential Services
Office of Health Systems Management