Incident Reporting Policy

Policy: Incident Reporting

Policy Number: 308 Policy Section: Quality
Owner: Head of Clinical & Quality Approved By: Paul Vogelman, COO
Effective Date: 7/08/2022 Date of Last Review:

SUD Specialty Group -- CA; Mental Health Specialty Group, P.A.; Mental Health Specialty Group NJ, PC; and Mental Health Specialty Group KS, P.A. (collectively, the "Group") contracts with Path CCM, Inc. d/b/a Rula Health ("Rula") for management and administrative support services. This policy applies to the Group and Rula.


Policy Statement

This policy recognizes the importance of the health, safety, and well-being of patients and team members. This policy identifies the procedures for reporting, tracking and analyzing incidents. Analysis of incidents are conducted to identify root causes and trends and used as a means to practice continuous quality improvement. 



This policy applies to all team members who become aware of a reportable incident. For purposes of this policy, the Group’s and Rula’s team members include individuals who would be considered part of the workforce such as employees, independent contractors, business team members, and other persons whose work performance is under the direct purview of Rula or the Group’s  business practices.



Incident: unexpected occurrence that has an adverse impact on a patient or team member. Definitions of specific reportable incidents are included with the body of the policy. 


Quality of care concern: 



  1. Reporting
    1. Upon discovery of an incident, team members (as defined in the applicability section above) will complete the Incident Reporting Form within 24 hours of the discovery or notification of the incident. 
    2. Incidents include: 
      1. Serious or potentially lethal suicide attempt
        1. This is a non-fatal, self-directed, intentional attempt to end one's own life that resulted in serious injury and as a result of the injury required emergency medical attention.
        2. Non-reportable events include: threats of suicide, attempts that do not results in emergency medical intervention, suicidal ideation
    1. Death (regardless of manner) of a patient who received any services within the 30 days prior to the incident date. 
    2. Patient related publicity event
      1. This is the potential or actual publicity or media attention involving Rula, the Group, or any patient who has received any services within the past 30 days.
      2. An example would be a patient who has been arrested for homicide or attempted homicide, or other potential substantial criminal activity
    3. Allegation of sexual contact by a patient against a provider.
    4. Medication error
    5. Any other serious incident not described above that seriously endangers the physical health or well-being of a patient. 
  2. Incident Investigation
    1. Once reported, incidents may require additional follow-up details and actions. 
    2. The team member who reported the incident will comply with the requests of the Head of Clinical Care, Compliance Officer, or designee for additional information as part of the investigation. 
  3. Incident Analysis: Upon the conclusion of an incident an analysis will be conducted that includes prevention efforts, causes, remedial action/corrective action that may include training, and recommendations for improvement. 
  4. Annual Report: As part of the Quality Assurance plan, an annual report of the analysis of all incidents will occur. 



A: Incident Reporting Form

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