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Introduced
HOUSE
FILE
254
BY
LOHSE
(COMPANION
TO
SF
48
BY
LOFGREN)
A
BILL
FOR
An
Act
relating
to
the
reporting
of
serious
reportable
events,
1
and
providing
penalties.
2
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
3
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Section
1.
NEW
SECTION
.
135S.1
Definitions.
1
As
used
in
this
chapter,
unless
the
context
otherwise
2
requires:
3
1.
“Department”
means
the
department
of
inspections,
4
appeals,
and
licensing.
5
2.
“Director”
means
the
director
of
inspections,
appeals,
6
and
licensing,
or
the
director’s
designee.
7
3.
“Facility”
means
a
hospital
as
defined
in
section
135B.1,
8
an
ambulatory
surgical
center
as
defined
in
section
135R.1,
or
9
a
pregnancy
resource
center.
10
4.
“Health
care
professional”
means
an
individual
licensed
11
under
chapter
148
to
practice
medicine
and
surgery
or
12
osteopathic
medicine
and
surgery,
a
physician
assistant
13
licensed
under
chapter
148C,
a
podiatrist
licensed
under
14
chapter
149,
an
advanced
registered
nurse
practitioner
licensed
15
under
chapter
152,
an
advanced
practice
registered
nurse
under
16
chapter
152E,
or
a
pharmacist
licensed
under
chapter
155A.
17
5.
“Pregnancy
resource
center”
means
a
nonprofit
entity
18
that
provides
pregnancy
support
services
as
defined
in
section
19
217.41C.
20
6.
“Serious
injury”
means
any
of
the
following:
21
a.
A
physical
or
mental
impairment
that
substantially
limits
22
one
or
more
of
the
major
life
activities
of
an
individual
or
a
23
loss
of
bodily
function,
if
the
impairment
or
loss
lasts
more
24
than
seven
days
or
is
still
present
at
the
time
of
discharge
25
from
an
inpatient
health
care
facility.
26
b.
The
loss
of
a
body
part.
27
7.
“Surgery
or
other
invasive
procedure”
includes
the
28
treatment
of
disease,
injury,
or
deformity
by
manual
or
29
operative
methods,
including
invasive
testing.
30
Sec.
2.
NEW
SECTION
.
135S.2
Facility
reporting
31
requirements.
32
1.
a.
Each
facility
shall
report
to
the
director
the
33
occurrence
of
an
applicable
serious
reportable
event
described
34
in
this
section
as
soon
as
is
reasonably
and
practicably
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possible,
but
no
later
than
fifteen
working
days
after
1
discovery
of
the
event.
2
b.
The
report
shall
be
filed
in
a
format
specified
by
3
the
director
and
shall
identify
the
facility
but
shall
not
4
include
any
identifying
information
for
any
of
the
health
care
5
professionals,
facility
employees,
or
patients
involved.
6
c.
The
director
may
consult
with
experts
and
organizations
7
familiar
with
patient
safety
when
developing
the
format
for
8
reporting
and
in
further
defining
serious
reportable
events
in
9
order
to
be
consistent
with
industry
standards.
10
2.
Serious
reportable
events
under
this
section
include
all
11
of
the
following:
12
a.
Surgical
events
including
all
of
the
following:
13
(1)
Surgery
or
other
invasive
procedure
performed
on
a
wrong
14
body
part
that
is
inconsistent
with
the
documented
informed
15
consent
for
that
patient.
Serious
reportable
events
under
this
16
subparagraph
do
not
include
situations
requiring
prompt
action
17
that
occur
in
the
course
of
surgery
or
situations
whose
urgency
18
precludes
obtaining
informed
consent.
19
(2)
Surgery
or
other
invasive
procedure
performed
on
the
20
wrong
patient.
21
(3)
The
wrong
surgery
or
other
invasive
procedure
performed
22
on
a
patient
that
is
inconsistent
with
the
documented
informed
23
consent
for
that
patient.
Serious
reportable
events
under
this
24
subparagraph
do
not
include
situations
requiring
prompt
action
25
that
occur
in
the
course
of
surgery
or
situations
whose
urgency
26
precludes
obtaining
informed
consent.
27
(4)
Retention
of
a
foreign
object
in
a
patient
after
surgery
28
or
other
invasive
procedure,
excluding
objects
intentionally
29
implanted
as
part
of
a
planned
intervention
and
objects
present
30
prior
to
surgery
that
are
intentionally
retained.
31
(5)
Death
during
or
immediately
after
surgery
or
other
32
invasive
procedure
of
a
normal,
healthy
patient
who
has
no
33
organic,
physiologic,
biochemical,
or
psychiatric
disturbance
34
and
for
whom
the
pathologic
processes
for
which
the
operation
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is
to
be
performed
are
localized
and
do
not
entail
a
systemic
1
disturbance.
2
b.
Product
or
device
events
including
all
of
the
following:
3
(1)
Death
or
serious
injury
of
a
patient
associated
with
the
4
use
of
contaminated
drugs,
devices,
or
biologics
provided
by
5
the
facility
when
the
contamination
is
the
result
of
generally
6
detectable
contaminants
in
drugs,
devices,
or
biologics
7
regardless
of
the
source
of
the
contamination
or
the
product.
8
(2)
Death
or
serious
injury
of
a
patient
associated
with
the
9
use
or
function
of
a
device
in
patient
care
in
which
the
device
10
is
used
or
functions
other
than
as
intended.
“Device”
includes
11
but
is
not
limited
to
catheters,
drains,
and
other
specialized
12
tubes,
infusion
pumps,
and
ventilators.
13
(3)
Death
or
serious
injury
of
a
patient
associated
with
14
intravascular
air
embolism
that
occurs
while
being
cared
for
15
in
a
facility,
excluding
deaths
associated
with
neurosurgical
16
procedures
known
to
present
a
high
risk
of
intravascular
air
17
embolism.
18
c.
Patient
protection
events
including
all
of
the
following:
19
(1)
Discharge
to
the
wrong
person
of
a
patient
of
any
age
20
who
does
not
have
decision-making
capacity.
21
(2)
Death
or
serious
injury
of
a
patient
associated
with
a
22
patient
disappearance,
excluding
events
involving
adults
who
23
have
decision-making
capacity.
24
(3)
Suicide,
attempted
suicide
resulting
in
serious
injury,
25
or
self-harm
of
a
patient
resulting
in
serious
injury
or
death
26
of
the
patient
while
being
cared
for
in
a
facility
due
to
the
27
patient’s
actions
after
admission
to
the
facility,
excluding
28
the
death
of
a
patient
resulting
from
self-inflicted
injuries
29
that
were
the
reason
for
admission
to
the
facility.
30
d.
Care
management
events
including
all
of
the
following:
31
(1)
Death
or
serious
injury
of
a
patient
associated
with
a
32
medication
error
including
but
not
limited
to
errors
involving
33
the
wrong
drug,
the
wrong
dose,
the
wrong
patient,
the
wrong
34
time,
the
wrong
rate,
the
wrong
preparation,
or
the
wrong
route
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of
administration,
excluding
reasonable
differences
in
clinical
1
judgment
on
drug
selection
and
dose.
2
(2)
Death
or
serious
injury
of
a
patient
associated
with
3
unsafe
administration
of
blood
or
blood
products.
4
(3)
Maternal
death
or
serious
injury
associated
with
labor
5
or
delivery
in
a
low-risk
pregnancy
while
being
cared
for
6
in
a
facility,
including
events
that
occur
within
forty-two
7
calendar
days
postdelivery
and
excluding
deaths
from
pulmonary
8
or
amniotic
fluid
embolism,
acute
fatty
liver
of
pregnancy,
or
9
cardiomyopathy.
10
(4)
Death
or
serious
injury
of
a
neonate
associated
with
11
labor
or
delivery
in
a
low-risk
pregnancy.
12
(5)
Stage
3
or
4
or
unstageable
ulcers
acquired
after
13
admission
to
a
facility,
excluding
progression
from
stage
2
to
14
stage
3
if
stage
2
was
recognized
upon
admission.
15
(6)
Artificial
insemination
with
the
wrong
donor
sperm
or
16
wrong
egg.
17
(7)
Death
or
serious
injury
of
a
patient
associated
with
a
18
fall
while
being
cared
for
in
a
facility.
19
(8)
The
irretrievable
loss
of
an
irreplaceable
biological
20
specimen.
21
(9)
Death
or
serious
injury
of
a
patient
resulting
from
the
22
failure
to
follow
up
or
communicate
laboratory,
pathology,
or
23
radiology
test
results.
24
e.
Environmental
events
including
all
of
the
following:
25
(1)
Death
or
serious
injury
of
a
patient
associated
26
with
an
electric
shock
while
being
cared
for
in
a
facility,
27
excluding
events
involving
planned
treatments
such
as
electric
28
countershock.
29
(2)
Any
incident
in
which
a
line
designated
for
oxygen
or
30
other
gas
to
be
delivered
to
a
patient
contains
the
wrong
gas
31
or
is
contaminated
by
toxic
substances.
32
(3)
Death
or
serious
injury
of
a
patient
associated
with
33
a
burn
incurred
from
any
source
while
being
cared
for
in
a
34
facility.
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(4)
Death
or
serious
injury
of
a
patient
associated
with
the
1
use
or
lack
of
restraints
or
bedrails
while
being
cared
for
in
2
a
facility.
3
f.
Potential
criminal
events
including
all
of
the
following:
4
(1)
Any
instance
of
care
ordered
by
or
provided
by
someone
5
impersonating
a
health
care
professional.
6
(2)
Abduction
of
a
patient
of
any
age.
7
(3)
Sexual
assault
on
a
patient
within
or
on
the
grounds
of
8
a
facility.
9
(4)
Death
or
serious
injury
of
a
patient
or
staff
member
10
resulting
from
a
physical
assault
that
occurs
within
or
on
the
11
grounds
of
a
facility.
12
g.
Radiologic
events
including
death
or
serious
injury
of
a
13
patient
associated
with
the
introduction
of
a
metallic
object
14
into
the
magnetic
resonance
imaging.
15
Sec.
3.
NEW
SECTION
.
135S.3
Root
cause
analysis
and
16
corrective
action
plan.
17
1.
Following
the
occurrence
of
a
serious
reportable
event
as
18
specified
under
section
135S.2,
a
facility
shall
conduct
a
root
19
cause
analysis
of
the
event.
20
2.
Following
the
analysis,
the
facility
shall
do
one
of
the
21
following:
22
a.
Implement
a
corrective
action
plan
to
address
the
23
findings
of
the
analysis.
24
b.
Report
to
the
director
any
reasons
for
not
taking
25
corrective
action.
26
3.
If
the
root
cause
analysis
and
the
implementation
of
a
27
corrective
action
plan
are
already
completed
at
the
time
an
28
event
is
required
to
be
reported,
the
findings
of
the
analysis
29
and
the
corrective
action
plan
shall
be
included
in
the
report
30
of
the
event.
31
4.
If
the
root
cause
analysis
is
completed,
but
32
implementation
of
a
corrective
action
plan
is
not
completed
at
33
the
time
an
event
is
required
to
be
reported,
the
findings
of
34
the
root
cause
analysis
and
a
copy
of
the
proposed
corrective
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action
plan
shall
be
filed
with
the
director
within
sixty
1
working
days
of
the
event.
2
Sec.
4.
NEW
SECTION
.
135S.4
Electronic
reporting.
3
1.
The
director
shall
design
the
serious
reportable
event
4
reporting
system
to
allow
a
facility
to
file
the
reports
5
required
under
this
chapter
by
electronic
means.
6
2.
The
director
shall
encourage
a
facility
to
use
the
7
electronic
filing
option
when
that
option
is
feasible
for
the
8
facility.
9
Sec.
5.
NEW
SECTION
.
135S.5
Relation
to
other
law
and
10
duties
——
confidentiality
of
data.
11
1.
a.
Serious
reportable
events
described
under
section
12
135S.2
do
not
constitute
child
abuse
as
defined
in
section
13
232.68
or
dependent
adult
abuse
as
defined
in
section
235B.2,
14
and
are
excluded
from
the
reporting
requirements
of
chapters
15
232
and
235B,
if
the
facility
makes
a
determination
within
16
twenty-four
hours
of
discovery
of
the
serious
reportable
event
17
that
this
chapter
is
applicable
and
the
facility
files
the
18
reports
required
under
this
chapter
in
a
timely
fashion.
19
b.
A
facility
that
determines
a
serious
reportable
event
20
described
in
section
135S.2
has
occurred
shall
inform
persons
21
within
the
facility
who
are
mandatory
reporters
of
child
abuse
22
under
section
232.69
or
dependent
adult
abuse
under
section
23
235B.3.
A
mandatory
reporter
otherwise
required
to
report
24
child
abuse
or
dependent
adult
abuse
is
relieved
of
the
duty
to
25
report
an
event
the
facility
determines
to
be
reportable
under
26
section
135S.2.
27
c.
The
protections
and
immunities
applicable
to
reporting
28
of
child
abuse
under
section
232.73
and
dependent
adult
abuse
29
under
section
235B.3
are
not
affected
by
this
section.
30
2.
a.
If
a
serious
reportable
event
is
reported
by
a
31
facility
in
compliance
with
this
chapter,
no
other
state
agency
32
or
licensing
board
is
required
to
conduct
an
investigation
of
33
or
obtain
or
create
investigative
data
based
upon
other
reports
34
of
the
same
event.
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b.
If
a
facility
is
required
to
report
a
serious
reportable
1
event
pursuant
to
another
state
law
that
meets
the
requirements
2
for
compliance
with
this
chapter,
the
department
shall
3
recognize
the
report
as
compliance
with
this
chapter
in
lieu
of
4
a
report
made
under
this
chapter
if
the
department
is
provided
5
a
copy
of
the
report.
6
3.
a.
Data
contained
in
the
following
records
are
7
confidential
records
under
section
22.7:
8
(1)
Reports
of
serious
reportable
events
made
to
the
9
director
by
a
professional
licensing
board.
10
(2)
Serious
reportable
event
reports,
findings
of
root
11
cause
analyses,
and
corrective
action
plans
filed
by
a
facility
12
under
this
chapter.
13
(3)
Records
created
or
obtained
by
the
director
in
reviewing
14
or
investigating
the
reports,
findings,
and
corrective
action
15
plans
under
subparagraph
(2).
16
b.
For
purposes
of
this
subsection,
the
reporting
facility
17
is
the
subject
of
the
report
or
data
under
chapter
22.
18
Sec.
6.
NEW
SECTION
.
135S.6
Director
duties
and
19
responsibilities
——
penalties.
20
1.
The
director
shall
establish
a
serious
reportable
event
21
reporting
system
designed
to
facilitate
quality
improvement
22
in
the
health
care
system.
The
reporting
system
shall
not
23
be
designed
to
punish
errors
by
health
care
professionals
or
24
facility
employees.
25
2.
The
reporting
system
shall
require
and
consist
of
all
of
26
the
following:
27
a.
Mandatory
reporting
by
facilities
of
the
applicable
28
serious
reportable
events
described
in
section
135S.2.
29
b.
Mandatory
completion
of
a
root
cause
analysis
and
a
30
corrective
action
plan
by
the
facility,
and
the
reporting
of
31
the
findings
of
the
analysis
and
the
plan
to
the
director,
or
32
the
reporting
of
reasons
for
not
taking
corrective
action.
33
c.
Analysis
of
reported
information
by
the
director
to
34
determine
patterns
of
systemic
failure
in
the
health
care
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system
and
successful
methods
to
correct
the
failures.
1
d.
Sanctions
against
facilities
for
failure
to
comply
with
2
reporting
system
requirements.
3
e.
Communication
from
the
director
to
facilities,
health
4
care
consumers,
and
the
public
to
maximize
the
use
of
the
5
reporting
system
to
improve
health
care
quality.
6
3.
In
establishing
the
serious
reportable
event
reporting
7
system,
the
director
shall
not
select
from
or
between
alternate
8
acceptable
medical
practices.
9
4.
The
director
shall
do
all
of
the
following:
10
a.
Analyze
serious
reportable
event
reports,
corrective
11
action
plans,
and
findings
of
the
root
cause
analyses
to
12
determine
patterns
of
systemic
failure
in
the
health
care
13
system
and
successful
methods
to
correct
these
failures.
14
b.
Communicate
to
individual
facilities
the
director’s
15
conclusions,
if
any,
regarding
a
serious
reportable
event
16
reported
by
a
facility.
17
c.
Communicate
with
relevant
health
care
facilities
any
18
recommendations
for
corrective
action
resulting
from
the
19
director’s
analysis
of
submissions
from
facilities.
20
d.
Publish
an
annual
report,
available
on
the
internet
site
21
of
the
department
that
does
all
of
the
following:
22
(1)
Describes,
by
facility
type,
serious
reportable
events
23
reported
by
facilities.
24
(2)
Outlines,
in
aggregate,
the
findings
of
root
cause
25
analyses
and
corrective
action
plans.
26
(3)
Makes
recommendations
for
modifications
of
state
health
27
care
operations.
28
5.
a.
The
director
shall
take
steps
necessary
to
determine
29
if
required
serious
reportable
event
reports,
the
findings
of
30
the
root
cause
analyses,
and
corrective
action
plans
are
filed
31
in
a
timely
manner.
32
b.
The
director
may
do
any
of
the
following:
33
(1)
Sanction
a
facility
for
failure
to
file
a
timely
34
serious
reportable
event
report,
conduct
a
root
cause
analysis,
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implement
a
corrective
action
plan,
or
provide
the
findings
of
1
a
root
cause
analysis
or
corrective
action
plan
in
a
timely
2
fashion.
3
(2)
Place
conditions
on
the
license
under
which
a
facility
4
operates
if
the
facility
fails
to
develop
and
implement
a
5
corrective
action
plan,
or
report
to
the
director
the
reason
a
6
corrective
action
is
not
needed.
7
6.
The
director
may
collaborate
with
the
department
of
8
health
and
human
services
to
administer
this
section.
9
Sec.
7.
NEW
SECTION
.
135S.7
Reports
from
licensing
boards.
10
1.
The
board
of
medicine,
the
board
of
physician
assistants,
11
the
board
of
nursing,
the
board
of
pharmacy,
and
the
board
12
of
podiatry
shall
maintain
a
record
of
all
complaints
that
13
come
to
the
attention
of
the
respective
board
that
in
the
14
judgment
of
the
board
qualify
as
a
serious
reportable
event
15
under
section
135S.2.
Within
thirty
working
days
of
making
a
16
determination
that
an
event
qualifies
as
a
serious
reportable
17
event,
the
respective
board
shall
forward
a
report
of
the
event
18
to
the
director,
including
the
name
and
address
of
the
facility
19
involved,
the
date
of
the
event,
and
information
known
to
20
the
board
regarding
the
event.
The
report
shall
not
include
21
any
identifying
information
of
any
health
care
professional,
22
facility
employee,
or
patients
involved.
23
2.
The
director
shall
forward
a
report
received
under
24
subsection
1
to
the
facility
named
in
the
report.
25
3.
a.
The
facility
shall
determine
whether
the
event
26
has
been
previously
reported
under
this
chapter,
and
shall
27
notify
the
director
as
to
whether
the
event
has
been
previously
28
reported.
29
b.
If
the
event
has
not
been
previously
reported,
the
30
facility
shall
make
a
determination
whether
the
event
is
31
reportable
under
this
chapter.
If
the
facility
determines
the
32
event
is
reportable,
the
date
of
discovery
of
the
event
for
33
purposes
of
this
chapter
shall
be
as
follows:
34
(1)
If
the
director
determines
the
facility
knew
or
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reasonably
should
have
known
about
the
occurrence
of
the
event,
1
the
date
the
event
occurred
shall
be
the
date
of
discovery
2
of
the
event
and
the
facility
shall
be
considered
out
of
3
compliance
with
this
chapter.
4
(2)
If
the
director
determines
the
facility
did
not
know
5
about
the
occurrence
of
the
event,
the
date
the
facility
6
receives
the
report
from
the
director
shall
be
the
date
of
7
discovery
of
the
event.
8
c.
If
the
facility
determines
the
event
was
not
reportable
9
under
this
chapter,
the
facility
shall
notify
the
director
of
10
that
determination.
11
Sec.
8.
NEW
SECTION
.
135S.8
Interstate
coordination
and
12
reports.
13
1.
The
director
shall
report
the
list
of
serious
reportable
14
events
described
under
section
135S.2
to
the
national
quality
15
forum,
and
through
the
national
quality
forum
to
other
states.
16
2.
The
director
shall
monitor
communications
by
the
17
national
quality
forum
of
amendments
to
the
list
of
serious
18
reportable
events
maintained
by
the
forum
and
shall
report
any
19
modification
to
the
list
to
the
general
assembly.
20
3.
The
director
shall
also
monitor
efforts
in
other
states
21
to
establish
a
list
of
serious
reportable
events
and
shall
22
make
recommendations
to
the
general
assembly
as
necessary
for
23
modifications
to
the
list
of
serious
reportable
events
under
24
this
chapter
to
maximize
uniformity
with
the
list
maintained
by
25
the
national
quality
forum
and
by
other
states.
26
EXPLANATION
27
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
28
the
explanation’s
substance
by
the
members
of
the
general
assembly.
29
This
bill
relates
to
the
reporting
of
serious
reportable
30
events
by
facilities
including
hospitals,
ambulatory
surgical
31
centers,
and
pregnancy
resource
centers.
32
The
bill
requires
each
facility
to
report
to
the
director
33
(director)
of
the
department
of
inspections,
appeals,
and
34
licensing
(DIAL)
the
occurrence
of
an
applicable
serious
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reportable
event
described
in
the
bill
as
soon
as
is
reasonably
1
and
practicably
possible,
but
no
later
than
15
working
days
2
after
discovery
of
the
event.
Reports
shall
be
filed
in
a
3
format
specified
by
the
director
of
DIAL
and
shall
identify
the
4
facility
but
shall
not
include
any
identifying
information
for
5
any
of
the
health
care
professionals,
facility
employees,
or
6
patients
involved.
7
Serious
reportable
events
include
surgical
events,
product
8
or
device
events,
patient
protection
events,
care
management
9
events,
environmental
events,
potential
criminal
events,
and
10
radiologic
events
detailed
in
the
bill.
11
The
bill
requires
that
following
the
occurrence
of
a
serious
12
reportable
event,
a
facility
shall
conduct
a
root
cause
13
analysis
of
the
event
and
shall
either
implement
a
corrective
14
action
plan
or
report
to
the
director
any
reasons
for
not
15
taking
corrective
action.
16
The
director
shall
design
the
serious
reportable
event
17
reporting
system
to
allow
a
facility
to
file
the
required
18
reports
by
electronic
means
and
shall
encourage
a
facility
to
19
use
the
electronic
filing
option
when
that
option
is
feasible
20
for
the
facility.
21
The
bill
provides
that
serious
reportable
events
under
the
22
bill
do
not
constitute
child
abuse
or
dependent
adult
abuse
and
23
are
excluded
from
the
child
abuse
and
dependent
adult
abuse
24
reporting
requirements,
if
the
facility
makes
a
determination
25
within
24
hours
of
discovery
of
the
serious
reportable
event
26
and
files
the
reports
required
in
a
timely
fashion.
27
A
facility
that
determines
a
serious
reportable
event
28
has
occurred
must
inform
persons
within
the
facility
who
are
29
mandatory
reporters
of
child
abuse
or
dependent
adult
abuse.
30
A
mandatory
reporter
otherwise
required
to
report
child
abuse
31
or
dependent
adult
abuse
is
relieved
of
the
duty
to
report
32
an
event
the
facility
determines
to
be
a
serious
reportable
33
event.
The
bill
does
not
affect
the
protections
and
immunities
34
applicable
to
reporting
of
child
abuse
and
dependent
adult
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abuse.
1
Additionally,
if
a
serious
reportable
event
is
reported
2
by
a
facility,
no
other
state
agency
or
licensing
board
is
3
required
to
conduct
an
investigation
of
or
obtain
or
create
4
investigative
data
based
upon
other
reports
of
the
same
event.
5
Also,
if
a
facility
is
required
to
report
a
serious
reportable
6
event
pursuant
to
another
state
law
that
meets
the
requirements
7
for
compliance
with
the
bill,
DIAL
shall
recognize
the
report
8
in
lieu
of
a
report
made
under
the
bill
if
DIAL
is
provided
a
9
copy
of
the
report.
10
Reports
of
serious
reportable
events
made
to
the
director
11
by
a
professional
licensing
board;
serious
reportable
event
12
reports,
findings
of
root
cause
analyses,
and
corrective
action
13
plans
filed
by
a
facility
under
the
bill;
and
records
created
14
or
obtained
by
the
director
in
reviewing
or
investigating
the
15
reports,
findings,
and
corrective
action
plans
are
confidential
16
records
under
Code
section
22.7.
17
The
director
shall
establish
a
serious
reportable
event
18
reporting
system
requiring
certain
information
as
detailed
in
19
the
bill.
20
The
director
shall
take
action
relating
to
serious
21
reportable
events
as
described
in
the
bill.
22
The
director
may
collaborate
with
the
department
of
health
23
and
human
services
to
administer
the
director’s
duties
and
24
responsibilities.
25
The
bill
requires
the
boards
of
medicine,
physician
26
assistants,
nursing,
pharmacy,
and
podiatry
to
maintain
27
a
record
of
complaints
that
come
to
the
attention
of
the
28
respective
board
and
are
determined
to
qualify
as
serious
29
reportable
events.
Within
30
working
days
of
making
a
30
determination
that
an
event
qualifies
as
a
serious
reportable
31
event,
the
respective
board
shall
forward
a
report
of
the
event
32
to
the
director.
The
director
shall
then
forward
the
report
33
to
the
facility
named
in
the
report
and
the
facility
shall
34
determine
whether
the
event
has
been
previously
reported
and
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shall
notify
the
director.
1
The
bill
requires
the
director
to
report
the
list
of
serious
2
reportable
events
to
the
national
quality
forum.
The
director
3
shall
monitor
amendments
to
the
national
quality
forum’s
4
list
of
serious
reportable
events,
monitor
efforts
in
other
5
states,
and
report
any
modification
to
the
list
to
the
general
6
assembly.
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