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Incident Approvals: Getting It Right the First Time

Agenda

• Brief Incident Management Review

• First Section Requirements

• Final Section Requirements

• Management Review

• Reasons for Non-approval

• Tracking Incidents

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What is Incident Management?

• Risk management process – assuring the health, safety, and rights of participants receiving services

• Standardized, web-based mechanism for reporting incidents in the Enterprise Incident Management system (EIM)

• Incident Management enables appropriate users to record incidents, track the status of recorded incidents, document corrective actions taken to prevent future occurrences, close incidents, and analyze aggregate incident data reported in EIM.

Provider Responsibilities

• Enter incidents that occur while providing services to a participant

• Timely documentation and finalization of incidents in EIM

First section due within 24 hours

Final section due within 30 days

• Communicate with the SC and families regarding incidents

• Provide appropriate follow-up and corrective action

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Supports Coordinator Responsibilities

• Review with participants and families how to report incidents, especially concerns regarding abuse, neglect or exploitation

• SCs need to enter incidents if directly reported to them by participants or families unless providers are responsible

• SCs need to review incident reports. Monitoring must include follow-up to ensure any corrective actions have been implemented and are effective.

BAS Report Types

• Individual Incidents

• Crisis Event

• Restraint

• Medication Error

• Optionally Reportable Event (Don’t use)

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BAS Incident Categories

What are the incidents that need to be reported?

24 Hour Reporting:

• Death

• Suicide Attempt

• Hospitalization

• Psychiatric Hospitalization

• Emergency Room Visit

• Abuse

• Individual to Individual Abuse

• Neglect

24 Hour Reporting:• Missing Person

• Injury Requiring Treatment Beyond First Aid

• Disease Reportable to the Department of Health

• Fire

• Misuse of Funds

• Rights Violation

• Law Enforcement Activity

• Crisis Event

• Emergency Closure

• Use of Restraint, even if authorized

72 Hour Reporting• Medication Error

Definitions and “How to” Resources

• For more detailed training on how to create, enter, and submit incidents, consult the Learning Management System.

• For incident definitions, please consult the Adult Autism Waiver Supports Coordinator Manual or Provider Manual.

• ACAP follows the ODP Incident Management Bulletin which also includes definitions.

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First Section Requirements

• INITIATOR INFORMATION

Include contact information (email address)

• DISCOVERY DATE

Should reflect when you were first made aware that an incident occurred

If the date of the actual incident is different, that date can be entered under the “Primary Category Date Occurred”

• If a report is late, the incident description should include an explanation as to why the report is late

First Section Requirements

• ACTIONS TAKEN TO PROTECT HEALTH AND SAFETY

Provide description of what was done during the event to protect the health and safety of participant and others

These actions are the immediate responses upon discovery of the incident

Actions may include but are not limited to:

• Checking for injuries, applying first aid, or medical attention

• Contacting Adult Protective Services (APS)

• Contacting law enforcement if a crime is suspected

• Separating the participant from the target of an investigation

• Protecting property

• Arranging alternative housing/respite

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Actions Taken to Protect Health and Safety Example:

Peggy Smith, the off duty support worker who discovered that Jen had been left unattended in a vehicle, immediately notified her supervisor and stayed with Jen until the support staff member returned to the vehicle. Peggy checked Jen to assure that she was not in any distress from being left alone. Upon the support staff member’s return, Peggy Smith informed the support staff worker that she had telephoned the supervisor and they were to immediately return to the day habilitation center. Peggy Smith returned with Jen and the worker to assure Jen’s safe return.

The support worker was suspended from her position pending the outcome of the investigation.

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• INCIDENT DESCRIPTION

Succinctly and chronologically detail what happened during the incident. Include dates, times, people involved, and the current status of the participant

Information should be objective, refrain for inserting subjective comments

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INCIDENT DESCRIPTION EXAMPLE:On Tuesday, January 12, 2016 at approximately 12:00 PM Peggy Smith, an off-duty staff member from ABC Agency, noticed Jen unattended in a vehicle in the parking lot of the Turkey Hill convenience store in Hazleton. Peggy reported that she was aware that Jen required 24 hour supervision and should not have been left alone in the vehicle. Peggy immediately notified her supervisor at ABC Agency to report that a staff member had entered the convenience store and had left Jen unattended with the keys in the ignition. Peggy waited with Jen for approximately 10 minutes until the staff member returned to the vehicle. Peggy informed the staff member that she had discovered Jen was alone and that she notified the supervisor and that they were instructed to return to the agency immediately. Peggy accompanied them back to the agency to assure Jen’s safety.

Other First Section Considerations• Law Enforcement category~ use “crisis intervention” as the secondary

category if police were called during a behavioral crisis

• Crisis Events ~ indicate if another incident needs to be filed as a result of the crisis event (e.g., ER visit, Psych Hospitalization)

• Use Link feature to “connect” incidents if they are directly related (e.g., crisis event and a resulting psychiatric hospitalization)

• When two separate incident reports are linked together (e.g., crisis event and ER visit), each report needs to capture the information relevant to the incident category. They should NOT be exact duplicates!

**Remember…. It is better to file a report if unsure and have it deleted than to not report and have the report be late**

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Final Section Requirements

• Complete Witness screen if others were present during the incident

• Target Information refers to the person being investigated

If Individual to Individual Abuse, use the individual’s first name initial, last name initial, and last 4 digits of social security number (WJ 1234)

• Complete Notifications screen - SC should be notified, avoid stating “team”

• Crisis Events require a team meeting within 10 days of crisis, please enter date of team meeting. If no meeting, please document why in the Additional Information Section

• .

Final Section RequirementsCORRECTIVE ACTIONS

• Critical part of incident management• Individualized risk mitigation• An overall approach to reduce the risk, impact, severity and/or

likelihood of reoccurrence• Focused not only on the current situation but also prevention of

future occurrence• Linked directly to BAS’s waiver performance measures which are

reported to The Center for Medicaid/Medicare Services (CMS)• CMS requires BAS to report “number and percent of confirmed incidents

of abuse, neglect, exploitation and unexplained death for which corrective action was taken”

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Final Section Requirements

CORRECTIVE ACTIONS

• Include what was done or will be done to address current situation and to prevent future occurrences

• Be specific

• Some examples of corrective actions (which are entered individually in EIM using the add button feature)

reviewing and updating BSP-CIP

retraining of staff

modifying environment

new instructional strategies

adding a new service to address an identified need

CORRECTIVE ACTIONS EXAMPLE

Corrective Action 1:

All agency personnel have been retrained in the agency’s policies regarding abuse and neglect, which included specific discussion on the definitions of each.

Completion Date: 1/18/2016

Responsible Party: Kathy Smith

Corrective Action 2:

All agency personnel who provide support to Jen have been retrained on her specific supervision needs and where to locate her information in her ISP if they

are not clear on her supervision needs.Completion Date: 1/24/2016

Responsible Party: Kathy Smith

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Final Section Requirements

• Thoroughly complete Hospitalization screen for medical hospitalizations and psychiatric hospitalizations

Do not finalize the FINAL SECTION until participant has been discharged.

• For all incident reports, use the Additional Information section to capture new information that was not previously captured in the first section, to clarify/correct previously reported information, and to update on the participant’s status

Final Section Considerations

• Remember to use the “add” feature correctly when entering information on screens that require multiple entries (e.g., witnesses, notifications, corrective action)

• Do not submit final section until the incident has been resolved

• Request a Report Extension if the Final Section cannot be completed in 30 days (e.g., participant has not been discharged from hospital, legal proceedings not completed)

• Request should be made BEFORE the report is late

• For extenuating circumstances only

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A few pointers about investigations

• Only select a certified investigator from your own provider organization or with whom you have an agreement

• Investigations need to begin promptly, within 24 hours

• Investigator must complete and submit their section before incident can be submitted to BAS

• Be sure the outcome/determination of the investigation is consistent throughout the incident sections (CI section and final section verification of incident classification screen)

Determinations: Confirmed, Not Confirmed, Inconclusive

• Providers can now assign the CI roles without going through BAS

Management Review

• After the final section is submitted by the provider, BAS has 30 days to review the incident

• Do not assume the incident has been approved

• Check in EIM periodically to see the status of the incident

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Frequent Reasons for non-approval of incidents• Incomplete reports

Final section submitted without completing each screen

Witnesses, Notifications screens left blank

• Lack of corrective action

Corrective Actions should be entered for most reports, especially Crisis Events, Law Enforcement, Psychiatric Hospitalization or any report that requires an investigation ( Abuse, Neglect, Rights Violation, Misuse of Funds)

• Incorrect incident categorization

Reclassification can be done in the final section under the Verification of Incident Classification screen

• Lack of detail

Report lacks detail to fully understand what happened

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BAS STATISTICS

Fiscal Year 14 – 15: 55% approval rate for first submissions of final sections

Fiscal Year 14 -15: 35% compliance with timeliness

• Recommend providers have their own procedures for tracking incidents through the incident report cycle

Be sure to check to make sure BAS approved the incident

• BAS is monitoring for incident reporting compliance and will issue Plans of Correction for non-compliance

Tracking of Incidents at Provider Level

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• Alerts are not given to providers to remind providers of upcoming due dates

• Utilize “My Dashboard” for tracking purposes

Using My Dashboard

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Incident Management Resources

• Supports Coordinator Manual

• Provider Manual

• Learning Management System (LMS)

EIM Captivate Tools

EIM User Guide

• For BAS-specific technical assistance:

ra-basprovidersupprt@pa.gov

• For EIM system issues/glitches:

c-hhcsishd@pa.gov (HCSIS Help Desk)