📚2026 ANNUAL STAFF TRAINING

8. INCIDENT REPORTING & GRIEVANCE PROCEDURES
GENERAL INCIDENT REPORTING

General Incident Reporting ensures safety, compliance, and early intervention. Not all incidents are sentinel events, but many sentinel events start as general incident.

  • General Incident: Safety, clinical, operational, or compliance concern without death or permanent harm
  • Sentinel Incident: Death, suicide attempt, or serious permanent harm requiring immediate escalation.
  • Mandated Reporting Incidents: Any situation in which a staff member has reasonable cause to suspect that a client or another individual is experiencing abuse, neglect, exploitation, or imminent danger, and the law requires the staff member to make a report to the appropriate authority (e.g., Child Protective Services, Adult Protective Services, or law enforcement), regardless of whether the concern is confirmed. We will cover this later in this training!

KEY RULE: Report any event impacting safety, care or compliance, including:

  • Client injury, fall, escalation
  • Medication errors or adverse reactions
  • Aggression, threats, or boundary concerns
  • HIPAA/privacy concerns
  • Staff injury or impairment
  • Facility or safety issues
Immediate Staff Response Should be:
  1. Ensure safety
  2. Notify supervisor or management
  3. Call emergency services if needed
  4. Complete and submit Incident Report (located in LS Library) within 24 hours to Executive Management.

All incident reports are confidential. Staff who report concerns in good faith will not face retaliation. Reports are reviewed by management for quality and safety improvement and may result in additional training, policy updates, or changes to a client’s care plan when appropriate.

SENTINEL INCIDENT REPORTING

Sentinel Events are unexpected occurrences involving the death or serious physical or psychological injury, or risk of one of those. These are to be reported to the admin and clinical director immediately. A “Sentinel Event Review” is conducted involving evaluation of incident, root cause analysis and future action plans. 

IMPORTANT NOTE: When an incident involves abuse or neglect, serious injury, illness or death, and/or violation of the provider Code of Conduct, Life Stone is obligated to Notify the Office of Licensing, legally responsible person and any applicable agency, which may include law enforcement AND Submit a preliminary written report to the Office of Licensing within 24 hours of the incident.

CLIENT GRIEVANCES

  1. Client Grievances & Procedures: Clients have a right to make complaints about their treatment. They shall be encouraged, whenever possible, to take complaints first to their provider, and thereafter to follow the lines of supervision or office management if the complaint is not addressed correctly. 
  2. Grievance Reviews: Life Stone management shall function as client advocates ensuring that complaints are acknowledged, reviewed and where possible, resolved. This process will be documented in eCharts as a Case Management Note.
STAFF GRIEVANCES

  1. Staff members are encouraged to raise concerns related to workplace issues, professional conduct, policies, or employment practices in a timely and respectful manner. Whenever possible, staff should first address concerns directly with the involved individual or their immediate supervisor. If the concern remains unresolved, staff may escalate the issue to Life Stone management.
  2. Life Stone is committed to maintaining a professional, respectful, and supportive work environment. All staff grievances will be reviewed promptly and handled with discretion. Appropriate steps will be taken to address concerns, and actions taken will be documented in accordance with organizational policy.

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