R380-200-5. Reports and Action Plan

  (1) Within 60 calendar days of determination of the patient safety event, the incident facility shall submit to the department a final report with an action plan that:

  (a) identifies changes that can be implemented to reduce risk or formulates a rationale for not implementing changes; and

  (b) where improvement actions are planned, identifies who is responsible for implementation, when the action will be implemented (including any pilot testing), and how the effectiveness of the actions will be evaluated.

  (2) The incident facility shall provide a final report to the facility's administration and the Department in a Department-approved electronic format that includes:

  (a) type of harm;

  (b) contributing factors;

  (c) preventability; and

  (d) actions taken.

  (3) The Department representative may submit a separate written dissenting report to the administrator of the incident facility and the Department if the Department representative identifies problems with the processes that limit the thoroughness or credibility of the findings and recommendations and that have not been corrected after reporting them to the designated responsible individual.

  (4) The incident facility may seek review of the dissenting report by filing a request for agency as allowed by the Utah Administrative Procedures Act and Department rule.

  (5) If a dissenting report is not challenged or is upheld on review:

  (a) the facility shall include it in the facility's records of the causal analysis; and

  (b) the Department may forward it, together with the facility's report, to the appropriate state agencies responsible for licensing the facility.