New Regulations for Developmental Disabilities Programs and Services
The following questions were raised during statewide regional training sessions for providers on the new regulations for developmental disabilities programs. We are making the questions and answers available on-line for those who were not able to attend the training.

• Administrative Issues
• Internal Protocol Issues
• Irregular Situations
• Issues Concerning Abuse and Neglect
• Issues Concerning Deaths
• Hospitalization
• Injury
• Incidents Reported To or Requiring Services of a Law Enforcement Agency or Fire Department
• Theft
• Medication Error
• Leave Without Notification (Elopement)
• Other
• Forms
• Standing Committee
• Family and/or Legal Guardian
• Resource Coordination

Click here for a directory of DDA Regional Offices and OHCQ's Main Phone Numbers.
For a directory of local health departments please go to the following website: http://mdpublichealth.org.

Administrative Issues

Q. Will the Office of Health Care Quality (OHCQ, formerly LCA) provide community providers with contact numbers for local health personnel to whom these reports are to be sent? Also, numbers to call when the Resource Coordination office is closed.?
A. The attached Directory of Health Officers provides information on your local health department. Most Resource Coordination offices give their emergency pager numbers on their answering machines for emergency contacts after working hours.

Q. If an agency is not sure whether or not to report an incident, what should occur?
A. Reporting procedures as outlined in the policy need to be followed as written. State residential centers (SRC) and community agencies would want to err in favor of reporting.

Q. Suggestion: For various reportable incidents that are serious, why have different time frames?
Abuse = 21 days
Neglect = 30 days
Incident (crime, etc) = 45 days
Can you simplify this by saying all reports are due within 30 days and not have different time frames?
A. The above timeframes are not for licensees, but are OHCQ/DDA's timeframes. In all circumstances, the licensee will be completing a report within 21 days.

Q. Suggestion: Make the report to OHCQ/DDA verbal with a follow-up fax, not either/or.
A. The intent is to give licensees flexibility in reporting. Licensees need to report in the manner most expedient to the situation.

Q. If you are involved with a situation concerning a family home, how far can you investigate?
A. An incident involving an individual's family home must be reported to Child Protective Services (CPS) or Adult Protective Services (APS).

Q. How does the policy relate to CPS referrals?
A. If an incident occurs in a DDA funded or licensed agency, the policy as written must be followed. In addition, CPS must also be notified. If the individual is a child and the Department of Social Services (DSS) is the funding source, then DSS must be notified. General rule of thumb: The funding source and the licensing source must be contacted.

Q. Incidents involving minors - Do they not need to be reported by the first hand witness or suspecting adult?
A. Yes, according to law suspecting adults or first hand witnesses must report incidents to local authorities.

Q. Can agencies see reports of OHCQ/DDA?
A. By law, OHCQ and DDA reports are not discoverable. You can, however, contact your regional DDA office for information on follow-up. Deficiencies are public documents and can be seen by anyone. Agency Board members may also receive deficiencies on a routine basis (see attachment).

Q. Will Protection & Advocacy agencies have access to reports?
A. The Maryland Disability Law Center (MDLC) is the State's Protection & Advocacy agency and it has access to a sampling of incident reports.

Q. If the Health Department is investigating, does DDA need to?
A. Yes, if OHCQ and DDA are aware of the situation, they will investigate.

Q. There was a minor controversy over the legal definition of "individual." Has it been resolved?
A. The definition for an "individual" can be found in the new DDA regulations, at 10.22.01.01B(25).

Q. Do we report injury to staff or others, such as community people?
A. The policy on injury addresses individuals, not staff. The licensee's policy and procedures protect staff. An incident must be reported if it involves an individual and someone in the community and/or if the police were involved.

Q. What are considered "working days?"
A. Working days are considered to be Monday through Friday, with the exception being if a holiday falls during that time frame.

Q. Can the director designate someone within the agency to be contacted if he or she is not available?
A. A designee can be named in the director's absence. However, this needs to be addressed in the licensee's internal protocol.

Q. If there is more than one individual involved in an incident, do copies of the incident report go into each individual's file?
A. Yes, but remember that the incident is viewed as one incident. The report needs to be retrieved under the names of all individuals involved. Remember that a licensee can also secure incident reports in a separate filing system.

Q. If an individual is participating in a supported employment program or in a community-placement and an incident occurs, does the agency include in the report the license # of the agency or the actual name of the place where the incident occurred?
A. The report would include both the name of the licensee and where the incident occurred.

Q. Can a time-out room be used for adults?
A. No, refer to the DDA regulations, 10.22.10.06D3.

Q. How many times can someone be restrained and are restraints reportable?
A. A restraint is triggered by a challenging behavior and can be implemented as documented in the individual's behavior plan. A restraint must be reported if unapproved or inappropriate, i.e. use of a mechanical restraint which is not allowed under the new regulations. Also, if a restraint is used in an emergency, the individual's team must be convened within 5 days to review the situation and action taken. Refer to the Behavior Support Services Program Service Plan chapter of the regulations, 10.22.10 for additional information on this subject.

Q. If DDA is funding Individual Support Services (ISS), do reports have to be completed?
A. Yes, reports are to be completed.

Q. What "conclusions" are to be documented in a report?
A. Conclusions should be supported by factual evidence and by findings of the investigation.

Q. Which term do we use, "individual" or "consumer?"
A. "Individual" is the term that is now used in the new DDA regulations.

Q. Are board members to be notified about incidents (internal & serious)?
A. Yes, this will happen automatically if board members are part of the licensee's standing committee.

Q. Can a day agency use its own discretion about who to report to?
A. No, it can not.

Q. Is there a time frame to expect to hear back from DDA/OHCQ with reports and if we cannot get a copy of the full investigation, can a courtesy letter notifying licensees that the case has been investigated and is being/has been completed?
A. OHCQ has developed a letter (see attachment) that will be sent to a licensee when OHCQ completes its investigation.

Q. If the regional office representative is not there, to whom should the agency talk?
A. Licensees should consult with their regional office; they all have a process in place.

Q. If CPS/APS was involved and investigated - how does OHCQ get involved?
A. According to the joint agreement with CPS/APS and OHCQ, CPS/APS takes the lead for investigating.

Q. Who monitors investigations completed by OHCQ?
A. As the State Protection and Advocacy Agency, MDLC can request to review investigations at any time.

Q. Who is a contact person for jurisdictional issues (e.g., group home in Montgomery County/MD but funding and placement was via DC)?
A. The agency's regional office can provide you with this information.

Q. Will DDA establish clear criteria for when and who to report incidents in a private family or individual home where ISS services are provided?
A. CPS or APS shall be notified of the alleged incident of an individual receiving ISS services. Refer to the policy under "Irregular Situations" for additional information.

Q. Will data collected from agencies be shared back with agencies periodically? (i.e. patterns involving certain staff, homes, individuals, etc., quarterly or annual trends)
A. Licensees should be looking at this information for themselves and taking action on such trends through their Internal Quality Assurance Plan. Regional offices may also share any patterns they recognize with licensees.

Q. It was not clear about DDA writing a report. The policy states they will write one in 45 days. When will the agency become aware of DDA's report? How will the agency know that the investigation is closed? How will the agency know if they are following-up and doing an effective response to the report?
A. The regional office can answer questions and follow-up if necessary with OHCQ regarding their report.

Q. What about incidents involving community or agency property damage: How or to whom are they to be reported?
A. If community damage. When the police are contacted, the licensee should follow the policy as written. This could also be reported under the "Other" category. DDA would like to be aware of a situation, so as not to be caught by surprise. If agency damage. This is assumed by the agency and not covered by this policy. If significant community damage occurs, this should be reported as "Other" as an internal investigation may apply.

Q. After 5 years, the agency purges or shreds files. Do DDA & OHCQ keep files longer? Why the length of time - 5 years?
A. OHCQ keeps its files slightly longer than 5 years. The 5-year length of time comes from the Uniform Business Record Act, which is state law.

Q. Page 4, #6 - Is this 21 working days or calendar days?
A. Calendar days.

Q. Under ISS, if an individual chooses to live in a complex cited for 800 violations of housing codes and refuses to move - is this reportable?
A. No, this is not a reportable situation. But... how is someone advocating for this individual? Is the ISS provider and Resource Coordinator, if involved, helping the individual to make informed choices?

Q. If day program only agency - something happens at the individual's home, friend's house - does agency need to report?
A. The licensee should be reporting to CPS/APS on issues such as these.

Q. Is DDA not to investigate unless advised by OHCQ?
A. OHCQ and DDA work collaboratively; however, OHCQ takes the lead in investigating an incident.

Q. What happens if an agency deems an incident as internal and later, after further investigation, determines that the incident should be considered serious? Is original time frame still to be used?
A. The licensee should report immediately upon making the re-determination. The licensee will not be penalized for not reporting the incident as serious previously because all of the facts were not available. This should not happen often and is not meant to be a mechanism to lengthen the reporting process and subsequent investigation and reporting requirements.

Q. What happens if an individual has a "bad day", several behavior outbursts over the course of a day involving several people. How many incident reports should be submitted?
A. All incidents may not be reportable; but if reportable, the report should reflect all individuals involved. If the incidents cross categories or involve different time frames, use separate reporting forms.

Q. What are the repercussions if timeframes for reporting are not adhered met?
A. All licensees are to respond in good faith. If repeat issues occur and are not reported on time and a pattern of not reporting is evident, OHCQ will act accordingly. Such a pattern could be grounds for sanction by DDA. Each licensee should also be looking at its process and any noticeable trends should be addressed in its quality assurance plan.

Q. Regarding 7 calendar days ... Does it mean that the investigation must be completed within 7 calendar days?
A. The investigation is not to be completed within 7 days. The results of the investigation must be forwarded to the licensee's standing committee within 7 calendar days.

Q. Does this policy relate to CSLA?
A. Yes.

Q. Will this policy be included in the regulations?
A. This policy is not included in the regulations; but it is referenced in the Administrative Chapter.

Q. Will a case number be given when a provider calls or faxes in the written report to OHCQ?
A. Yes, OHCQ will call the provider back to give a case number.

Q. Can licensees call OHCQ to obtain case numbers?
A. Yes.

Q. What if individuals are in their own home in which an agency provides support and something happens days prior, would you still be required to report the incident?
A. Yes, this needs to be reported. The licensee needs to determine if DDA and OHCQ need to be involved or CPS/APS.

Q. Relating to individuals outside the program (approved for long-term care outside agency but still funded)... Are we under the same reporting requirements?
A. Consult with your regional office. The outside agency may have their own reporting requirements.

Q. Who is the state protection and advocacy agency?
A. The Maryland Disability Law Center (MDLC).

Internal Protocol Issues

Q. Who evaluates the internal review procedure of an state residential center (SRC)? If that isn't done regularly, what would bring about an evaluation?
A. OHCQ, as part of their annual survey process, reviews all policies and procedures of all licensees, including SRC's.

Q. Can the director designate someone within his/her agency to be contacted if he/she is not available?
A. A designee can be named in the director's absence. However, this needs to be addressed in the licensee's internal protocol.

Q. Who completes the reportable incident from the agency, the person who sees it or the person who reports it?
A. The licensee's internal protocol should address this issue.

Q. Should one person in the agency to do all the reporting?
A. This is up to the licensee's internal protocol.

Q. Where are the records for reportable incidents kept? In an individual's file or separate binder?
A. The licensee's internal protocol needs to address this issue. OHCQ recommends that the agency keep the reports in a place where they are easy to locate. Reports need to be available to the individual and his/her team, but confidentiality of records also must be maintained.

Q. Who does the internal investigation- director, manager, supervisor, or Safety Review Board?
A. This information should be included in the licensee's internal protocol, and can vary with the licensee.

Q. When should agency protocols be developed?
A. A licensee’s internal protocols must be in place now.

Q. Is the protocol to be sent to DDA headquarters for approval or kept at the agency?
A. The licensee's internal protocol should be kept at the agency, to be reviewed as any other policy/procedure would be by OHCQ.

Q. When an internal policy is developed does it need to be approved by anyone other than the policy and procedure committee?
A. The licensee's Board of Directors should also approve the internal protocol.

Q. In the situation where an individual is in residential and day services, within the same agency, who is responsible for reporting?
A. This information should be included in the agency's internal protocol.

Irregular Situations

Q. If an injury occurs at the day program that resulted in treatment at an area hospital, is the residential agency responsible for conducting the internal investigation?
A. In this irregular situation, the day program would investigate and communicate its findings to the residential program. The residential agency may need to continue treatment as recommended by the treating licensed health care practitioner. If the residential agency is not satisfied that the incident was handled appropriately, it too can bring the incident to the attention of OHCQ and the appropriate DDA regional office for follow-up and to assure that the injury was reported.

Q. For a day program, if an incident occurs at home, and no abuse or foul play is suspected, is the community agency responsible for filing an incident report?
A. If the incident occurs at the individual's home, which is not within the DDA system, the agency does not need to report the incident. If abuse/neglect is suspected, CPS or APS should be contacted.

Q. Time frame for resolution among two community agencies in regards to internally investigated reports. For example: A day program discovering agency files internally investigated incident and reports alleged incident to the residential program where the incident occurred. When can the day program expect resolution or follow-up from the residential program?
A. If the discovering SRC/community agency does not feel that the other SRC/community agency is handling the incident properly, the discovering SRC/community agency should contact OHCQ and the DDA regional office and request follow-up to assure appropriate action was taken by the SRC/community agency. There should be continued communication between SRC/community agencies on an ongoing basis.

Q. An individual gets off of the van at the day program upon arrival in the morning with bruises discovered by the day program. It appears that the incident may have occurred on the van or at the residential home. Who does the investigation? Residential provider? Day provider? Or both?
A. The discovering agency begins the process, but potentially the day program could be responsible for completing the investigation. Refer to the Irregular Situations section of the policy and always feel free to contact your regional office for guidance.

Q. When an SRC has an individual going to outside day program, is there a sharing of final written reports?
A. No, but the discovering agency is entitled to know that progress is being made and the final outcome of the investigation.

Q. How can the one provider ensure follow-up of another?
A. You can always contact your regional office and ask for information regarding follow-up.

Q. How is another agency with which the individual is involved notified? If the individual is injured in the day program, the day program reports to DDA and family, but also should have to report to residential provider.
A. Refer to the Irregular Situations section of the policy. Remember to also report to OHCQ.

Q. What is the guideline for an incident investigation when both day and residential agencies claim that the incident did not happen there?
A. Licensees need to investigate and make conclusions whether or not it happened at their agency. Details of the investigations should prove that it did or did not happen there. Remember, you can contact your regional office for guidance.

Q. When we say serious & irregular, what is the difference in how we respond to report?
A. An irregular situation can be either internally investigated or seriously reportable. Refer to the policy for clarification or contact your regional office.

Issues Concerning Abuse and Neglect

Q. While working, an individual touches the breast of another individual through her clothing. It was not consensual. Is this reportable to police?
A. If this type of incident was an accident, the police do not need to be contacted. If the incident fits the definition of abuse as listed in Appendix 1A, the provider should follow the policy as written.

Q. Does a report need to be filed each time an individual slaps another and does 911 need to be called each time?
A. According to the way the policy currently reads, yes. A report must be completed, and the police contacted. In these situations, licensees may want to look at separating people. In addition, is a behavior modification plan (BMP) in place? Is this a pattern of abuse? Are staffing patterns inadequate, etc.? Please contact Joan Rumenap or your regional office for assistance with those difficult situations. This is one area in which we hope to revise the policy.

Q. Do all physical fights between individuals need to be reported?
A. According to the current policy, yes. Common sense should prevail. However, at a minimum, such an incident should at least be internally investigated. An incident may increase to serious reportable if an injury results in an emergency room visit or hospitalization. Licensees should look to see if a pattern of abuse occurs as the agency could be held liable for neglect for not reporting. If necessary, a team meeting should occur to discuss issues and the possible need for a BMP or revised BMP to be developed. Keep in mind, that if the victim alleges abuse, or wants to press charges, this is a serious reportable incident. If there is a pattern of aggression, is the aggressor being placed in an environment with vulnerable people? Is there adequate supervision? This too could be seen as neglect on the licensee's part.

Q. What happens if there is insufficient staff supervision, call the police?
A. This type of incident needs to be reported and investigated as it may or may not be neglect. Circumstances need to be taken into consideration such as what is the individual's need for supervision? Is this a pattern? Intent?, etc.

Q. When agencies make a decision about reporting neglect, should "intent" be considered? And how does "intent" mesh with quality assurance and follow-up and what type of report is done?
A. Intent does not drive the policy. The type of report that is required by the policy and follow-up operate independently. Intent does mesh with quality assurance and should be addressed in a licensee's policies and procedures.

Q. Does Maryland have a central abuse registry? Can we get stricter laws concerning databases for staff who have been convicted or had allegations of abuse and do convictions or charges show up on police background checks?
A. Maryland does not have a central abuse registry. We are currently looking at Delaware, Virginia, and Ohio state laws to see how those states established registries. For private companies doing background checks and using a potential employee's Social Security Number, pending charges can be identified. Background checks through the State Police only reveal convictions through fingerprints.

Q. Individual A's behavior (door slamming, yelling) causes Individual B's self-abusive behavior (biting self, head banging) What type of reporting should be done?
A. The safety and well-being of all individuals is of paramount concern in all incidents. Licensees should look at the circumstances surrounding the incident and take action accordingly, such as separating people, providing appropriate level of supervision, etc. For this particular incident, reporting on injuries sustained by Individual B depends on the type of injury sustained. Although the incident itself may not be reportable, the team needs to be aware of the situation and take preventive action. If not, again this could be considered neglect.

Q. Appendix 2A #6 - Other. Comment to consider: Hepatitis B can be sexually transmitted. A sexual abuse investigation would not be necessary for all individuals with Hepatitis B. However, this policy appears appropriate for suspicious circumstances suggestive of sexual abuse.
A. Licensees need to consider circumstances surrounding the contraction of Hepatitis B and depending on the circumstances an investigation may need to be completed.

Q. Does the agency call the police if someone is bi-polar, cycling, and not getting the attention they need? Is this neglect?
A. As in any situation where the individual is not receiving the proper medical or other care, this could be considered neglect, but would be better addressed through the Individual Plan process.

Q. In a supported employment situation where abuse occurs, does the agency immediately contact the police rather than follow the policy?
A. The policy calls for immediate police contact.

Q. In a non-licensed agency, if an abuse/neglect occurs - who is contacted?
A. CPS or APS.

Q. An individual receives day programming via DDA funding, but not residential,the day staff note a bruise, who is contacted?
A. APS must be contacted if abuse is suspected to have occurred outside the DDA system.

Q. If a staff member raises his/her voice to an individual, is it abuse?
A. Not necessarily, the licensee needs to evaluate each situation. For example, is the staff person raising his/her voice due to an individual's hearing loss or is there loud music playing in the background?

Q. Who informs the agencies about who is going to do abuse investigations?
A. OHCQ or DDA will inform the licensee with this information.

Q. What if the family is not taking care of medical needs, is this neglect? (individual lives with family)
A. This situation needs to be discussed with the individual and his/her team. If necessary, CPS or APS must be contacted.

Q. If an ISS provider witnesses a service recipient abusing his/her child and reports it to CPS, does DDA want to know?
A. No, we have no authority to investigate. However, if the police are involved, then it would be reported according to the policy.

Q. Are there not legal responsibilities involved with reporting an abuse case? (I thought legally that you could be held liable if you do not report an incident within 24 hours.)
A. Yes, there is a mandated reporting law. Refer to the CPS/APS Law and professional licensure statutes for additional information.

Q. How can that lapse of time be allowed with investigating sexual abuse/physical abuse cases?
A. Of first and foremost importance is that the health and safety of all individuals involved must be assured, e.g., getting medical treatment, separating the alleged abuser and victim, etc. The police would respond immediately and the DDA reporting requirement is immediate according to the policy.

Q. If abuse happens on a Saturday, Sunday, or holiday, are there on-call emergency phone numbers?
A. The police should be notified immediately according to the policy. OHCQ and DDA Regional Offices have on-call Administrative Duty Officers for emergencies during non-working hours.

Q. Do you report suspected abuse to the guardian if you suspect the guardian of being the abuser?
A. In this situation, it is advisable to report to the police and ask for their direction. From an advocacy perspective, the licensee may want to begin the process for changing the guardian status.

Q. What if you have a client who routinely has pica behavior, is this considered a serious reportable incident?
A. The policy applies if there is injury or neglect involved. The licensee will want to assure that a BMP is in effect addressing the pica, and is being followed. It may be that the BMP needs to be revised to address current needs.

Issues Concerning Deaths

Q. How and where do we document that family does not want to be contacted except in case of death?
A. This documentation should be kept in the individual's file.

Q. Death- questions regarding contacting the police.
A. Refer to attached memo, which references the law, from the Chief Medical Examiner's Office.

Q. Do natural or expected deaths have to be reported to the police?
A. According to the law, yes.

Q. Death...(Appendix 1C) Who do we report to at the health departments?
A. Contact your local health department for guidance.

Q. Does death from natural causes have to be reported to police?
A. According to the current policy, the police must be contacted. The police determine whether to contact the Medical Examiner's Office if they feel that further investigation is needed.

Q. Can report of death be left on regional office voice mail?
A. Yes, you can leave a message to report a death, but remember to follow-up with a fax.

Q. If the individual is living at home with family, does a report of death have to be filled out?
A. Yes, a report must be completed if the individual is receiving any type of DDA funded service.

Q. If a client is attending day program & receives supports from two separate agencies, who is responsible for reporting death?
A. Follow the directions outlined in the Irregular Situations section of the policy. When in doubt, consult your regional office.

Hospitalization

Q. When an individual steps off of a curb and you take them to the emergency room to see whether his or her ankle is sprained or broken. Is this a serious reportable occurrence?
A. Yes, if the individual is taken to the emergency room it is considered an unplanned hospitalization.

Q. Can the possible need for hospitalization be documented in 45 day nursing reviews?
A. If the condition is considered to be chronic, it is recommended that the documentation be in the individual's plan.

Q. Do you need the name and address of the hospital on the reports for hospitalization?
A. The name of the hospital should be included in the description of the incident.

Q. Must it be reported if independent individuals who manage their own health care admit themselves into the hospital?
A. If the individual is served by an agency, then the policy must be followed as written.

Q. Must it be reported if an individual is hospitalized in another state while visiting his or her family, but lives with a DDA licensed agency?
A. Only if the hospitalization is the result of the care that the individual was receiving prior to visiting his or her family.

Q. Does hospitalization include outpatient surgery such as biopsy, sedation for minor incision or dental care?
A. If the hospitalization is planned, according to the policy, it must be reported.

Q. What about incidents or injuries for which we may consider sending the individual to the hospital for treatment; when an HMO or other third-party payer may not be willing to pay?
A. Follow the policy according to what the licensed health care practitioner tells you. If in doubt, contact OHCQ or your regional office. Licensees should document their advocacy role to assure that the individual is getting the services he or she needs.

Q. Appendix 1D - Hospitalization. What constitutes documentation as noted? How should it be provided?
A. Specific documentation must be in the individual's plan, not just the existence of a condition but that future hospitalization is anticipated related specifically to that condition.

Q. What if the individual must be hospitalized for recurring seizures that are documented?
A. This case would be an internal investigation due to documentation of the chronic condition being in the individual's plan.

Q. Appendix 1D- Hospitalization. If an individual went to the emergency room but received no treatment, should the agency file a report?
A. Yes.

Q. There are many times when an individual is ill on the weekend, goes to the emergency room, and is diagnosed with an upset stomach, should this type of incident still be reported?
A. Yes.

Q. If you have an individual who goes to the emergency room for frequent false reports of chest pains, he or she is seen but not treated, should this always be reported?
A. This scenario can be internally investigated if such behavior is documented in the individual's plan.

Q. If an individual comes back from the hospital with a communicable disease, does this need to be reported?
A. Yes, and may also need to be reported to your local health department. Remember, no matter how many people are involved, it only requires one report.

Injury

Q. Is choking reportable?
A. Yes. If the choking happens for the first time and does not result in treatment, injury or hospitalization, it can be reported as an internally investigated incident. Licensees may want to consider a swallowing evaluation if choking occurs on a regular basis

Q. Must Level I injuries be reported in the quarterly report?
A. If a Level I injury rises to the level that it is considered an Internally Investigated Incident, yes, it needs to be reported on the quarterly report.

Q. There seems to be some confusion concerning terms like laceration, sprains, etc.?
A. For additional information on terms, consult your agency nurse or the American Red Cross Manual.

Q. Question about open vs. unopened blisters and in what category these should be?
A. Refer to Appendix 1E for the appropriate category for open and unopened blisters. The licensee may also refer to the Red Cross First Aid Manual for additional information and pictures.

Q. Certain conditions are not injuries, should they be reported? For example: types of shock.
A. In most cases, shock would probably require an emergency room visit or hospitalization, therefore requiring a report to be made. Licensees need to look at each situation separately. If it doesn't fall under any category, use "Other" or contact your regional office/regional nurse for guidance.

Q. What about a human or animal bite that has not punctured or broken the skin? Should this be considered serious incident?
A. This would be a Level II incident and could possibly change. When in doubt, contact your nurse. If it is a human bite, this may also be abuse.

Q. What should be done when a semi-independent individual is working in supported employment and suffers an eye injury. A week later, the agency learns that the employer had assisted with a first aid kit. Should the incident still be reported?
A. Yes, the incident must be reported.

Q. Who makes the assessment as to the level of the injury? Does it have to be the nurse?
A. Only the nurse or another licensed health care practitioner can make this assessment.

Q. Can a burn be changed from an internally investigated incident to serious? They can convert so easily from 1st, 2nd degree, to 3rd degree needing medical attention.
A. Burns can change to a different category, depending on their severity. Complete follow-up as necessary and report.

Q. What category would these medical issues be: - A child with a gastronomy tube that came out and was replaced by a nurse?
- A tracheotomy tube that came out and required edical attention by the nurse to replace it?
A. Both of these medical issues would be considered routine medical care and would not be reportable unless the client goes to the hospital.

Q. What if a child has a wound, the current nurse or doctor is following up with the treatment; however the infection or wound becomes more serious?
A. In this medical issue, the nurse would assess the situation and a report may need to be completed if the individual went to the hospital.

Q. What should be done if a child has behavior, SIB, hitting himself. There is a program in place, however he strikes himself and it occurs once/week.
A. With this issue, it is suggested that the individual and his or /her team review the data to determine the effectiveness of the plan. The plan may need to be revised. The severity of the SIB must be considered, i.e., did the SIB result in injury, leave a mark and/or bruise that would require reporting?

Q. What if you have an individual who routinely has pica behavior, is this considered a serious reportable incident?
A. The policy applies if there is injury or neglect involved. The licensee will want to assure that a behavior plan is in effect addressing the pica, and is being followed. It may be the case that the behavior plan would need to be revised to address current needs.

Incidents Reported To or Requiring Services of a Law Enforcement Agency or Fire Department

Q. Possession of illegal substance, guns, etc. If you suspect an individual is using an illegal substance, maybe during a home visit, are you required to report it to the authorities? What is the category for this incident?
A. If the weapon is legal, there is no need to report. However this should be documented in the person's Individual Plan. For illegal substances, guns, etc., yes the authorities must be notified. Licensees want to assure that the individual is getting the help they need, such as rehabilitation, support groups, etc.

Q. Is illegal substance use, which is monitored by a probation officer, a reportable incident?
A. Yes.

Q. More definition on 2F - reporting to fire department. For example: Fire Department called for CO detector. There was not a problem. The detector was faulty and replaced; yet as I read 2F, the fire department was called.
A. Faulty equipment would not be a reportable incident.

Q. Our police department does not want any questioning done if there is an abuse reported, what do we do about internal reporting?
A. The licensee should document that the police requested that they not complete an internal investigation. Remember to get the officer's name, phone number, and report number.

Q. Suppose you have an individual that likes to call 911, ride in the ambulance, but does not need medical attention, is this reportable?
A. No, this does not need to be reported. However, this is a behavioral issue that would need to be addressed in the Individual Plan per regulations.

Q. At state residential centers, where security is considered a law enforcement agency, do we report to them?
A. Yes.

Q. Suppose someone is arrested, released on bail, and is awaiting a court date? Is this reportable?
A. Yes.

Q. If an ISS individual is incarcerated, does DDA want to know?
A. Yes, due to funding issues.

Q. What happens if during their investigation, OHCQ or the police tell you to stop your investigation but your board tells you to continue? Are there liability issues?
A. Licensees should always follow the advice of OHCQ or their local police. Otherwise, they may be at risk of obstructing justice.

Q. Are agencies held accountable for time frames once police departments are involved?
A. Time frames must met based on the information that the licensee has and continue to update as necessary.

Q. What does the agency do with the staff person, if accused of abuse, while the police are completing their investigation?
A. The responsibility of the licensee is to ensure the safety and well being of all individuals involved in an incident. Licensees should address this issue and their response in their internal protocol. If necessary, licensees may consult their legal counsel to address this question.

Q. If an ISS provider receives a call from the parent of an ISS individual stating that her son, the individual, is holding a knife to his older brother and asks for your assistance without involving the authorities, who needs to be notified?
A. The parent should be urged to contact 911 immediately.

Q. Appendix 1F - Law enforcement. Agencies frequently call police for individuals with behavioral episodes, i.e., physical aggression or property destruction, that are out of control. Police are also called for elopement. Must these incidents be reported each time to OHCQ or can this be documented in the individual's record as behavioral and internally investigated?
A. Yes, if the police are called, each incident must be reported as a serious reportable incident.

Q. Suppose you see a pattern developing with an individual but it has not developed to the level of a serious reportable incident? What should be done?
A. An internal investigation should be completed to determine needed action in order to address the pattern.

Q. Suppose the individual does not want an incident reported to the police? What should be done?
A. According to the policy the incident must be reported to the police. It is important to note that reporting to the police does not always mean an investigation will be completed by the police. We are continuing our dialogue with self advocates and self advocacy groups regarding this issue.

Q. On occasion, licensees have been told that there is no police report number, what should the provider do?
A. Licensees should document when they spoke to the police, what they were told, and the officer's name and phone number.

Theft

Q. In the case of theft, is it a $50 replacement value or the actual cost of the item(s) stolen?
A. Actual cost.

Q. If an individual's habit of theft is targeted as a behavior within a behavior modification plan (BMP), is it still a serious reportable offense if the theft (i.e. from another individual) is over $50?
A. Yes.

Q. If an individual has a documented theft problem, and a behavior plan developed to address the problem, must an internal investigation be completed if the behavior plan is followed?
A. Yes.

Q. Suppose the individual steals another individual's money, how is it reported? Is an internal investigation required?
A. Refer to the policy for clarification as it depends on the amount stolen whether it is internally investigated or a serious reportable incident.

Medication Error

Q. If an individual refuses to take his or her medication and the nurse on call is notified, is this an incident for internal investigation?
A. An individual refusing to take his or her medication is not a medication error. However, the nurse must be notified of the refusal so that the safety and health of the individual can be addressed.

Q. If an individual refuses his or her medication two or more times, is this an incident for internal investigation?
A. As stated above, refusal to take one's medication is not considered a medication error. A licensee would want to keep track of how often an individual is refusing to take his or her medication so that the nurse can assess possible health and safety issues. In the case where the individual is refusing to take his or her medication on a regular basis, the individual and his or her team would want to discuss this so that other issues may be brought to light, i.e., the individual does not like taking medication in pill form, does the individual have a swallowing problem, etc. Also, alternative medications or treatments may be explored with the doctor.

Q. How does the policy on medication errors apply to individuals authorized by their physician to self-medicate?
A. The policy addresses the condition of the individual and adverse effects, not who gives the medication.

Q. Are "self-medication" errors reportable incidents?
A. Yes, if adverse effects are present. If this happens frequently, additional training or assistance to the individual who self medicates may be necessary.

Q. With a self-medicating individual living in a semi-independent home with drop-in supervision, it is discovered that this individual is taking too many or has too many pills left over and you, as the nurse, revoke this individual's self-medicating privilege, does this need to be reported?
A. If adverse effects appear, yes, this needs to be reported. It may also come under another category and not necessarily be a medication error, such as an emergency room visit. Remember, if an individual is admitted to the hospital due to a medication error, it gets reported both as a medication error and as a hospitalization.

Q. In the case of a medication dosage error, if the doctor tells you what to look for and the action to take, is this still a reportable incident?
A. If there are adverse effects, yes it is a reportable incident.

Q. Which non-medical professional is qualified to determine if a medication error may require agency nurse consultation?
A. No non-medical professional is qualified to determine if a medication error requires nursing consultation. All medication errors must be reported to the nurse.

Q. If you call the doctor and he or she says that there will no adverse effects, must it still be reported?
A. In this case it would be documented as an internal incident.

Q. If a family member is at your facility and wants to administer medications and they are not DDA trained, are they allowed to do so at your facility?
A. In a licensed setting, medication distribution is considered a delegated act and staff must be trained. If the family member is trained, yes they can administer medications. It is suggested that this issue be addressed individually in each licensee's internal protocol. Family members should respect the duties of the staff members. The Nurse Practice Act allows family members to administer medications when the individual is in the family member's home.

Q. If an individual goes home and his or her parent does not medicate correctly with repercussions later, what can you do about that?
A. This would be handled as a medication error. Communication between the licensee and the family should occur as well so that such an incident can be avoided in the future.

Q. What about a medication error involving a mental health facility that is discovered by a DD provider?
A. As for all incidents that fall under an irregular situation, licensees may need to report to an outside agency to follow-up such as the health department, APS, CPS, etc.

Q. If the pharmacy makes a medication error, is that reportable? (maybe hospitalization?)
A. If there are adverse effects, yes. The authorized medication person should be checking the medication prior to administering. It is recommended to have a three way check: Check the physician's order, Medication Administration Record (MAR), and the prescription label each time a medication is given.

Q. If someone misses a dose of medication, where does it fall in reporting?
A If adverse effects are present, a report must be made to the nurse.

Q. If there is a medication missed, depending on the type of medication, should the physician be notified?
A. The nurse must notify the licensed health care practitioner whenever a medication is missed.

Q. If someone who was not certified gives a medication , is this a policy or personnel issue?
A. This is a violation of the delegation of nursing function which is practicing nursing without a license. For additional information, refer to the Nurse Practice Act, Nurse Delegation Law, 10.27.11.

Leave Without Notification (Elopement)

Q. Appendix 1I, should elopement cases be reported to the police?
A. Refer to Appendix 2I for reporting criteria. The police do not necessarily need to be contacted in all cases of elopement. However, if the individual's absence constitutes an immediate danger to himself or herself or others, the police should be contacted.

Q. What about the individual who says he or she is leaving and goes; is this elopement?
A. Refer to Appendix 1I.

Q. Part of the individual behavior plan for elopement is to call police within 30 minutes. Does this need internal investigation or report to DDA/OHCQ?
A. Yes, if the police are called. Remember, if the individual is in danger, this is a serious reportable incident and policy should be followed as written.

Other

Q. Does State law require that all suicide attempts must be reported to the police?
A. State law does not require that all suicide attempts be reported to the police. All suicide threats should be taken seriously and we recommend that the individual be referred to a licensed health care practitioner for further evaluation.

Q. What if a communicable disease is involved?
A. Communicable diseases are reportable. DDA is currently working on a list of communicable diseases that must be reported to your local health department.

Q. Are blood-borne pathogens reportable?
A. Yes, this should be reported under "Other" if considered to be a communicable disease. Refer to your local health department as to what is reportable. Remember that OSHA or MOSHA guidelines must be followed for exposure to a communicable disease.

Q. If an individual comes back from the hospital with a communicable disease, does this need to be reported?
A. Yes, and also may need to be reported to your local health department. Remember, no matter how many people are involved, it only requires one report.

Q. Behavioral outburst. Threats to kill someone. Where or how are these incidents reported?
A. If an individual does something that falls under the policy, it needs to be reported. If it does not fall under the policy, a team meeting should occur to address the issue.

Forms

Q. Is the narrative section on page 3 to be included with Appendix 4 or the final report due within 21 days?
A. On some copies of the policy, the narrative section was incorrectly copied on the back of Appendix 4. The description of the Narrative Section is guidelines for the 21-day report for Serious Reportable Incidents.

Q. If you have reported serious incidents as required, must they still be contained on the quarterly report to OHCQ?
A. The quarterly report is only for Internally Investigated Incidents.

Q. Regarding the quarterly Incident Report, if the individual is not funded by the DDA and therefore does not have an individual ID#, what should be indicated in that column?
A. For Appendix 5, the Quarterly Incident Report form, the individual ID# is the individual's Social Security Number.

Q. If you do not have incidents in a quarter, do you still need to send a report?
A. Yes, all you need to do is draw a line through the report and state that there were no incidents during the particular quarter.

Q. Who needs to complete, sign and send the Incident Report form, and the quarterly incident report form, the director or the assistant director? Does the person signing and completing the forms need to have a B.A. or M.A. degree?
A. The answer to this question is different for each licensee and should be addressed in the licensee's protocol.

Q. Can we still use the androgynous figure for incident reports to pinpoint areas of injury to the individual involved?
A. Yes, although it is not required.

Q. What is the site # for family support/individual support services that are provided in family home or only in the community?
A. There is no site # for a family home. Licensees can put "N/A" on their form.

Q. Do the quarterly reports concern DDA funded or licensed individuals?
A. DDA does not license individuals. DDA licenses or funds the provider. For the entire policy, including quarterly reports, reports must be made on behalf of individuals receiving services from a DDA licensed provider or a provider funded by the DDA.

Q. When is the quarterly report due?
A. The quarterly report for internally investigated incidents is due April 15, July 15, October 15, and January 15. The incidents to include on the report should include those internally investigated incidents that occurred during the period of the previous quarter. For example, the report due July 15 should include internally investigated incidents from April 1 through June 30. Remember to submit the quarterly report to both OHCQ and your regional office.

Q. Do we need to complete quarterly reports for both regions if our agency crosses two regions?
A. Yes, but the report need only be sent to the regional office that provides administrative support to your agency as well as to OHCQ.

Q. When or what will DDA/OHCQ respond to on the quarterly reports? What is the feedback on those reports and when will the agency receive feedback from DDA?
A. At any time, OHCQ and DDA can request additional information on an internally investigated incident. OHCQ will be reviewing internally investigated incidents during their survey of a licensee. Both DDA and OHCQ will be looking at the licensee's Internal Quality Assurance Plan for trends and applicable action plans to be implemented.

Q. For the 21-day report, must the report be sent to DDA & OHCQ?
A. Yes.

Q. What is the written report?
A. Appendix 4 is the written report.

Q. If we complete Appendix 4 in its entirety, and send it in as the initial report, do we still need to do a 5-day written report?
A. No.

Q. Must all parts of the forms be completed?
A. All parts of the forms must be completed. If not applicable, put N/A.

Standing Committee

Q. Does a multi-agency standing committee count another agency's members as "outside agency" representatives?
A. No. All staff are considered inside representatives.

Q. Are board members considered agency or community representatives on standing committees?
A. Board members are counted as agency (inside) representatives.

Q. If your agency has a behavior management committee, must half of the members be non-agency?
A. Yes.

Q. Who pays for interpreters to be present at the standing committee meetings?
A. Interpreters would be paid by the licensee.

Q. All incidents are supposed to be reviewed by the standing committee. Must the members be provided the entire investigation or is a synopsis with availability to all information appropriate?
A. The full investigation must be forwarded to the standing committee for its review.

Q. Please clarify, if you are on the agency Standing Committee, you can not investigate.
A. This is correct. Anyone who is directly involved would be considered in a conflict of interest situation under the review of the investigation. One can investigate or review, but not both.

Q. The standing committee will meet within 7 days of what time frame?
A. The policy states that the standing committee must receive the report within 7 calendar days following closure of the matter, not necessarily that the committee meets.

Q. Is there a minimum size to a standing committee?
A. No, refer to the new DDA regulations, 10.22.02.14E for more information on standing committees.

Q. What does "individual" mean on the standing committee?
A. Refer to the DDA regulations 10.22.01.01B(25) for the definition of an "individual".

Family and/or Legal Guardian

Q. If an individual has a family member, but the family is not involved, should the family be notified?
A. Yes, unless otherwise noted in the person's individual plan. We should not assume that just because a family member is not involved on a regular basis that they would not want to know about an incident.

Q. Could the automatic notification of an advocate or guardian possibly infringe on the individual's rights if they don't want that person notified? Where the individual is his or her own guardian and is legally competent, at what point is notifying the family a violation of the individual's human rights?
A. If the individual has a legal guardian, you must notify that person in the case of a reportable incident. If the individual has reached the age of majority and does not have a guardian, the SRC or community agency must respect the individual's wishes as documented in his or her individual plan and note such on the Appendix 4 report.

Q. Is there a time frame requirement for reporting to the family and/or advocates? For example, resource coordinator?
A. No, however, it is suggested that contact be made in a timely fashion.

Q. Are families and service coordinators only notified in cases of serious reportable and not in cases of internal investigation and not reportable?
A. According to the policy, families and resource coordination must be notified only in the case of a serious reportable incident. However, it is important to keep families and resource coordination aware and to keep the lines of communication open. Even if families are not regularly involved, the licensee should contact them unless otherwise noted in the individual's plan. The family makes the decision as to what level they wish to be involved.

Q. Must agencies know if there is a legal guardian?
A. Yes, the licensee should routinely know this information and document it in the individual's plan.

Q. Concerning reporting to families, suppose the individual does not have a guardian and he or she does not want his or her family to know, but the family is involved? Should the family still be notified?
A. Unless otherwise noted in the person's individual plan, it is strongly recommended to notify family and advocates as outlined in the person's individual plan. We are continuing our dialogue with self-advocates and self- advocacy groups regarding this issue.

Resource Coordination

Q. Does resource coordination receive a written report of the incident?
A. No, resource coordination does not receive a written report of the incident.

Q. Is there a time frame requirement for reporting to the family and/or advocates, i.e. case manager or service coordination?
A. No, however, it is suggested that contact be made in a timely fashion.

Q. Is the DDA case manager now required to report to OHCQ and their regional office and how much follow-up should they do?
A. Yes. Under the new regulations, the resource coordination agency is considered a licensee and needs to follow the regulations and the Policy for Reportable Incidents, as any other licensee would if an incident occurs when they are involved with an individual.

Q. Are families and resource coordinators notified only in cases of serious reportable and not in cases of internal investigation and not reportable?
A. According to the policy, families and the resource coordinator must be notified only in the case of a serious reportable incident. However, it is important to keep families and resource coordination aware and to keep the communication lines open. Even if families are not regularly involved, the licensee should contact the family unless otherwise noted in the individual's plan. The family makes the decision as to what level they wish to be involved.

Q. Suggestions: Perhaps supervisors of resource coordinators could be given quarterly and annual reports as well as DDA to share that information with the appropriate resource coordinator. Families should be told minor incidents upon their next contact with agency, i.e., when the parent comes to pick up his or her son or daughter, the parent could be told "Oh, he got bruised falling down the steps on Monday."
A. It is important to note that delayed notification promotes distrust. The quarterly report is not intended for resource coordination. The interactive purpose of the team process should be happening, and the resource coordinator should be notified by the agency involved.

Q. Will resource coordination get a written report within 5 days of the discovery of a serious reportable incident?
A. No, notification to resource coordination by the agency may be verbal.

Q. What happens when the individual does not have a resource coordinator?
A. For the development and implementation of the individual plan, refer to the new DDA regulations, 10.22.05.03B for information on this subject.

Q. Is the family or advocate to be notified of the results of an investigation?
A. If the family or advocate is the complainant, refer to Health-General Article, §7-1003, Annotated Code of Maryland.

Q. When is the family or advocate notified, as soon as incident is reported or after the investigation is complete with results?
A. The family, advocate, or guardian should be contacted in a timely manner. Remember, late notification breeds distrust.

Q. What is the resource coordinator's role in police related incidents? If an agency feels that the police should not be notified and wants to classify the occurrence as "internally investigated" but the resource coordinator and the individual feel the police should be notified, do resource coordinators reserve the right to notify the authorities?
A. If the individual feels that the police should be involved, then the police should be contacted. If the resource coordinator has additional concerns about whether an incident should be reported as internal or serious, the resource coordinator should contact the regional office for guidance.

Q. Are resource coordinators to complete Appendix 4 if they are the witness to an incident and the agency is not? Or, does the resource coordinator relay the information to the agency for them to complete Appendix 4?
A. The person who normally fills out Appendix 4 is the person or agency that investigates the incident. It is unlikely that resource coordinators would be completing Appendix 4, unless the incident occurred while they were working with the individual.

Q. Since resource coordinators are responsible for also reporting incidents although agencies may have already done so, does OHCQ want to receive a blurb faxed containing our knowledge of what happened? Since it was made clear that faxes were preferable to phone calls, can the report be an informal fax or must it be a formal letter, etc?
A. An informal fax, or phone call, can be made to OHCQ and your respective regional office to assure that the incident was reported.

Q. Reporting to resource coordination, does this include individuals residing in an SRC if a resource coordinator is involved?
A. Yes.

Developmental Disabilities Administration
Regional Offices Main Phone and Fax Numbers

Central Region
Phone: 410-902-4500
Fax: 410-581-6170

Eastern Shore Region
Phone: 410-334-6920
Fax: 410-334-6929

Southern Region
Phone: 301-262-5100
Fax: 301-362-5130

Western Region
Phone: 301-791-4670
Fax: 301-791-4019

Click here for Office of Health Care Quality Main Phone and Fax Numbers