(a) It is the intent of this Part to require an incident management system, including the reporting, investigation, review, correction, and monitoring of certain events or situations, in order to protect individuals receiving services (to the extent possible) from harm; ensure that individuals are free from abuse and neglect; and to enhance the quality of their services and care.

(b) A primary function of the reporting of certain events or situations is to enable a governing body (see glossary, section 624.20 of this Part), executives, administrators and supervisors to become aware of problems, to take corrective measures, and to minimize the potential for recurrence of the same or similar events or situations. The prompt reporting of these events and situations can ensure that immediate steps are taken to protect persons receiving services from being exposed to the same or similar risk.

(c) The reporting of certain events or situations in an orderly and uniform manner facilitates identification of trends, whether within a facility or class of facilities, by one or more agencies, or on a statewide basis, which ultimately allows for the development and implementation of preventive strategies.

(d) It is the intent of this Part to require a process whereby those events or situations that endanger a person's wellbeing while under the auspices of an agency, which are defined in section 624.3 of this Part as "reportable incidents," and in section 624.4 as "notable occurrences," are reported, investigated and reviewed, and protective, corrective, and remedial actions are taken as necessary.

(e) It is not the intent of this Part to mandate that every potentially harmful event or situation attributable to or involving a person receiving services while under the auspices of an agency, be recorded as a reportable incident or notable occurrence in accordance with this Part. It is the responsibility of the agency to determine how events or situations involving persons receiving services that are under the auspices of the agency or sponsoring agency, other than reportable incidents and notable occurrences (as defined in sections 624.3 and 624.4 of this Part), are to be documented, processed, corrected, (including corrective actions to be taken for the protection and/or safety of all those exposed to potential harm), monitored, and analyzed for trends through the development of policies and procedures that are in compliance with 14 NYCRR, and to develop a mechanism for review to ensure compliance with such policies and procedures.

(f) It is the intent of this Part to require a process whereby the governing body ensures the effectiveness of the identification, recording, investigation, review, and corrective actions with regard to events or situations involving persons receiving services referenced within this Part. This must be achieved through the establishment of the governing body's own protocol, which may include, but not be limited to, regular review of the minutes of the incident review committee and periodic attendance at that committee's meetings.

(g) It is the intent of this Part to hold the governing body and the chief executive officer (see glossary, section 624.20 of this Part) responsible for the management of incidents. However, the chief executive officer may designate staff members to assume specified responsibilities to facilitate the day to day process, and these designations must be set forth in writing in agency policies and procedures and made known to all staff and others with a need to know.

(h) Though failure on the part of an agency to provide appropriate services may not meet the definition of an incident or notable occurrence as defined in section 624.3 or 624.4 of this Part, OPWDD has, pursuant to statute, the authority to investigate or cause the investigation of conduct, performance, and/or alleged neglect of duty.

(i) It is the intent of this Part to require a process for facilities that is in full compliance with the provisions of section 29.29 of the Mental Hygiene Law.

(j) Facilities and programs that are certified or operated by OPWDD, except those programs that are certified under paragraph 16.03(a)(4) or (5) of the Mental Hygiene Law, are required to comply with relevant provisions of article 20 of the Executive Law (Protection of People with Special Needs) and article 11 of the Social Services Law (Protection of People with Special Needs), and to implement regulations promulgated by the Justice Center for the Protection of People with Special Needs (Justice Center).