Description

Calling for a major overhaul of the Incident Reporting and review System at State psychiatric and developmental centers, this Commission report indicated there are "fundamental flaws" in the system. The study concluded that the Incident Reporting and review System produces approximately 100,000 reports annually, with multiple layers of internal review at the facility level, and of external review by Regional Offices, Central Offices, boards of visitors, Mental Health Information Service and, occasionally, by the Commission.