§ 29.29 Incident reporting procedures.
    The   commissioners  of  the  offices  of  mental  health  and  mental
  retardation and  developmental  disabilities  of  the  department  shall
  establish  policies  and uniform procedures for their respective offices
  for the  reporting,  compilation,  and  analysis  of  incident  reports.
  Incident  reports  shall, for the purposes of this chapter, mean reports
  of accidents and  injuries  affecting  patient  health  and  welfare  at
  facilities. These policies and procedures shall include but shall not be
  limited to:
    1. The establishment of a patient care and safety team at the facility
  level  which  shall  include  but not be limited to a: physician, nurse,
  social worker and  therapy  aide,  to  investigate  and  report  to  the
  facility director on:
    (i) suicides or attempted suicides;
    (ii) violent behavior exhibited by either patients or employees;
    (iii)  frequency  and severity of injuries incurred by either patients
  or employees;
    (iv) frequency and severity of injuries occurring on individual  wards
  or in buildings at such facility;
    (v) patient leave without consent;
    (vi) medication errors; and
    (vii)  recommendations  for corrective actions in response to incident
  reports to ensure the care and safety of all patients.
    2. The establishment of cumulative record keeping of incident  reports
  which identifies patient and employee involvement.
    3.  A  compilation  of  uniform and measurable information, first on a
  facility basis, then on an office-wide basis, that will  indicate  where
  the greatest number and types of incidents occur.
    4. Each facility shall aggregate its data monthly for the director and
  that  aggregated  information shall be submitted, at least semi-annually
  to  the  commissioner  of  the  office  of  mental  health  and  to  the
  commissioner  of  the  office  of  mental  retardation and developmental
  disabilities.
    5. The commissioners shall transmit a  copy  of  any  report  received
  pursuant  to subdivision four of this section to the state commission on
  quality of care and advocacy for persons with disabilities.
    6.