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Unusual Incident Reporting and Investigations - Substance Abuse

A safe environment is essential to providing quality substance abuse treatment services. It is the responsibility of each provider and their staff to ensure that one is provided. Title 29, Chapter 23 of the District of Columbia Municipal Regulations (Chapter 23) requires substance abuse treatment facilities and programs to report unusual incidents to the Department of Health and to conduct investigations following the occurrence of certain unusual incidents. Facilities/programs are required to have in place policies and procedures for the investigation and reporting of unusual incidents.

Access the Unusual Incident Report Form [PDF]

CDCR 29-2330.1 states that:
A substance abuse treatment facility or program shall develop and implement written policies and practices related to individual abuse, neglect and unusual incidents to insure prompt reporting and a prompt, impartial investigation and review.

CDCR 29-2330.2 states that:
A substance abuse treatment facility or program shall provide written notice to the Department of any unusual incident which results in physical injury or death, within 24 hours of the incident or within 24 hours of the program director becoming aware of the incident.

Addressing unusual incidents and investigating them in a timely and thorough manner helps reduce risk by providing the basis for corrective action to avoid similar situations in the future and helps monitor and record losses that occur at the facility/program. There are three steps that must be followed when addressing unusual incidents: (1) recording, (2) reporting and (3) investigating.

A record should be made of every unusual incident that is reported. The facility/program must maintain a file system to preserve these records. Chapter 23 requires a facility/program to maintain these records, along with copies of all complaints, investigative findings and actions taken, in a secure file, with a separate file for those records that may be of a criminal nature.

Under Chapter 23 substance abuse treatment facilities and programs are required to investigate any allegations of abuse, neglect, sexual assault, suspicious physical injuries or deaths of a patient, visitor or staff, alleged incidents of a criminal nature, or any threats to health or safety. The investigation must be initiated within 24 hours of reporting of the incident and must be completed within 10 calendar days.

A substance abuse treatment facility/program is required to report its investigative findings to the Department of Health within 24 hours of completing the investigation. A facility/program may request an extension of 10 days from the Department of Health to complete an investigation. Reports of unusual incidents and requests for extensions are to be directed to:

Keela S. Seales, Esq.
Risk Manager and Privacy Officer
Addiction Prevention and Recovery Administration
1300 First Street NE, Suite 315
Washington, DC 20002
(202) 727-9569 phone
(202) 727-1763 confidential fax
keela.seales@dc.gov

For further information regarding unusual incident reporting and investigations please refer to Section 2330 of Title 29 Chapter 23 of the DC Municipal Regulations or contact Keela S. Seales, Risk Manager and Privacy Officer, Addiction Prevention and Recovery Administration.

Contact TTY: 
711