Section 144-114-3 - Standardized Procedures3.1 Notification by next business day. The healthcare facility must notify the SET of a sentinel event (Section 1.22) by the next business day after the event occurred or the next business day after the facility discovers that the event occurred. The notification must include but is not limited to the date and time of notification, the name of the health care facility, the type of sentinel event, and the date and time the sentinel event occurred. See 22 M.R.S.A. §8753(1). 3.2 Notification Procedure. Immediately upon discovery of a sentinel event, the facility must act in accordance with its notification procedures as required by Section 2.1 of these rules.3.2.1 Notification of the discovery of a sentinel event must not be delayed secondary to internal deliberations or pending autopsy or medical examiner results.3.2.2 Within 1 business day of the discovery of a sentinel event, the healthcare facility must send the department-approved sentinel event notification form to the SET by facsimile or encrypted e-mail.3.3 Situational Notification Considerations.3.3.1 Inter-facility Transfer Notification. A sending facility is required to submit to the SET notification regarding a sentinel event when the transfer to another facility is unrelated to the natural course of the patient's illness or underlying condition; or unrelated to the proper treatment of that illness or underlying condition in its healthcare facility.3.3.2 Discharge Follow-up Notification.3.3.2.1 A facility is required to submit to the SET notification by the next business day after the event occurred or the next business day after the facility discovers that the event occurred regarding a sentinel event involving a patient with amajor permanent loss of function that is present at the time of discharge that is unrelated to the natural course of the patient's illness or underlying condition or proper treatment of that illness or underlying condition in a health care facility.3.3.2.1.1 If within 14 days of discharge from a health care facility, evidence is discovered that the major loss of function was not permanent, the facility must submit the department-approved Functional Evidence form with supporting documentation to the SET, and the health care facility is not required to submit the root cause analysis (RCA) report required in Section 4 of these rules. See 22 M.R.S.A. §8752(4-A)(B).3.3.2.2 A facility is required to submit to the SET notification by the next business day after the event occurred or the next business day after the facility discovers that the event occurred when a sentinel event involving a death or major permanent loss of function occurs within 48 hours of treatment or procedure at a health care facility that is unrelated to the natural course of the patient's illness or underlying condition; or unrelated to the proper treatment of that illness or underlying condition in a health care facility.3.3.2.3 A facility is required to submit to the SET notification by the next business day after the event occurred or the next business day after the facility discovers that the event occurred when the suicide of a patient occurs within 48 hours of discharge from a health care facility.3.3.3 Notification of sexual assault. If one or more of the following criteria is met, the facility is required to submit sentinel event notification regarding a sexual assault that occurred within or on the grounds of a health care facility: 3.3.3.1 Any staff-witnessed sexual assault;3.3.3.2 Sufficient clinical evidence obtained by the health care facility to support allegations of sexual assault; or 3.3.3.3 Admission by the perpetrator of a sexual assault that occurred on the premises.3.3.4 Notification of serious event. A facility is required to submit sentinel event notification regarding a serious event lasting more than seven days or still present at the time of discharge from a facility.3.4 SET Case Review. Upon receipt of a notification or report of a sentinel event, the SET completes an initial review and may take other action that it determines to be appropriate pursuant to these rules. The facility must comply with the following requirements for the SET case review: 3.4.1 Provide a copy of the patient's medical record.3.4.2 Provide a timeline of the event.3.4.3 Present details of the event.3.4.4 Schedule SET conference with the CEO or Administrator.3.4.5 Schedule SET de-briefing regarding the findings with the facility.3.5 Immediate Jeopardy. The division personnel responsible for sentinel event oversight shall report to the division's licensing section only incidences of immediate jeopardy and each condition of participation in the federal Medicare program related to the immediate jeopardy for which the provider is out of compliance.10- 144 C.M.R. ch. 114, § 3