Critical Incident Management Guide

Transcription

1 Critical Incident Management Guide Effective April 1, 2013 Content by NM Human Services Department Medical Assistance Division Quality Bureau and Formatted by United Healthcare HSD Critical Incident Reporting System_Training Guide Revised Page 1 of 24

2 TABLE OF CONTENTS INTRODUCTION... 3 INCIDENT MANAGEMENT PRINCIPLES... 3 AGENCY INCIDENT MANAGEMENT SYSTEMS... 3 INCIDENT MANAGEMENT STATUTES AND REGULATIONS... 4 DEFINITION OF REPORTABLE INCIDENTS... 4 ABUSE, NEGLECT, AND EXPLOITATION... 4 DEATH... 4 OTHER REPORTABLE INCIDENTS... 5 REPORTING GUIDELINES... 5 ADULT PROTECTIVE SERVICES... 5 INCIDENT REPORTING... 5 CRITICAL INCIDENT REPORTING FLOW CHART... 6 INSTRUCTIONS FOR LOGIN AND USERNAME\PASSWORD MANAGEMENT... 7 INSTRUCTIONS FOR COMPLETING AND SUBMITTING REPORTS... 8 HOME PAGE... 8 CRITICAL INCIDENT REPORTING FORM... 9 SECTION 1-CONSUMER INFORMATION SECTION 2 - DESCRIPTION OF INCIDENT SECTION 3 AGENCY INFORMATION: SECTION 4 ADMINISTRATIVE INFORMATION: REPORT SUBMISSION SEARCH FOR A CRITICAL INCIDENT REPORT PRINT AND FAX CRITICAL INCIDENT REPORT DIARTY ENTRY INFORMATION PROCESS CONCLUSION Page 2 of 24 HSD Critical Incident Reporting System_Training Guide

3 INTRODUCTION The Human Services Department/Medical Assistance Division/Quality Assurance Bureau (HSD/MAD/QAB) Incident Management System describes the statewide reporting requirements for all incidents involving Consumer s served under Medicaid funded, Home and Community Based service programs. Community agencies providing Home and Community Based services are required to report critical incidents to State as described in this guide. These programs include the CoLTS C Waiver, the Personal Care Option Program (PCO) and Mi Via. All allegations of Abuse, Neglect, and Exploitation of a Consumer must be reported, as well as any incidents involving Emergency Services, Hospitalization, the Death of a recipient, the involvement of Law Enforcement, and any Environmental Hazards that compromise the health and safety of a recipient. In recognition of the need to report such incidents, the State of New Mexico provides statutes and regulations which define the expectations and legal requirements for properly reporting recipient involved incidents in a timely and accurate manner. Agencies that do not comply with incident reporting requirements are in violation of State statutes and federal regulations, and may be sanctioned up to and including termination of their provider agreement by a Managed Care Organization or by the HSD, Medical Assistance Division. Incident Management includes 1) the policies and procedures an agency develops to be able to respond to incidents, 2) the ongoing training it provides to its caregivers and recipients, and 3) actions the agency takes to continuously improve the quality of care provided to their Consumer s as well as ensuring their health and safety. Incident Management is a critical component of a Quality Assurance/Improvement Program. INCIDENT MANAGEMENT PRINCIPLES All adults and children receiving Home and Community Based services should be able to enjoy a quality of life that is free of abuse, neglect, and exploitation. Staff must receive initial and ongoing training to be competent to respond to, report, and document incidents, in a timely and accurate manner Recipients, legal representatives, and guardians must be made aware of and have available incident reporting processes Any individual who, in good faith, reports an incident or makes an allegation of abuse, neglect, or exploitation will be free from any form of retaliation. Quality starts with those who work most closely with persons receiving services. AGENCY INCIDENT MANAGEMENT SYSTEMS All agencies providing Medicaid funded services that are required to report critical incidents are also required to develop and implement an incident management system that at minimum maintains, tracks and trends data from the reports and includes the data in quality assurance activities. HSD Critical Incident Reporting System_Training Guide Revised Page 3 of 24

4 INCIDENT MANAGEMENT STATUTES AND REGULATIONS NMSA 1978, Section Adult Protective Services mexico/2006/nmrc/jd_ch27art7 b845.html NMAC Department of Health NMAC B. (14), (15) Personal Care Options NMAC E. CoLTS C Waiver provider dfs/8_307_18_colts_c_regulations.pdf NMAC Mi Via Waiver DEFINITION OF REPORTABLE INCIDENTS ABUSE, NEGLECT, AND EXPLOITATION 1. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish to a recipient. 2. Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness to a recipient. 3. Self Neglect is defined as an act or omission by an incapacitated adult that results in the deprivation of essential services or supports necessary to maintain minimal mental, emotional or physical health and safety. 4. Exploitation is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a Consumer s belongings or money without the Consumer s consent. DEATH 1. Unexpected Death is a death caused by an accident or an unknown or unanticipated cause. 2. Natural/Expected Death is a death caused by a long term illness, a diagnosed chronic medical condition, or other natural/expected conditions resulting in death Consumer. Page 4 of 24 HSD Critical Incident Reporting System_Training Guide

5 OTHER REPORTABLE INCIDENTS 1. Environmental Hazard is defined as an unsafe condition that creates an immediate threat to life or health of a Consumer. 2. Law Enforcement Intervention is defined as the arrest or detention of a person by a law enforcement agency, involvement of law enforcement in an incident or event, or placement of a person in a correctional facility. 3. Emergency Services refers to the provision of emergency services to a recipient that result in medical care that is not anticipated for this recipient, and that would not routinely be provided by a primary care provider. REPORTING GUIDELINES ADULT PROTECTIVE SERVICES The New Mexico Adult Protective Services (APS) Act mandates: Any person having reasonable cause to believe an incapacitated adult is being abused, neglected or exploited shall immediately report that information to the department. Incidents involving suspected/alleged abuse, neglect, and exploitation must be referred immediately to: Adult Protective Services Statewide Central Intake Telephone: (866) FAX: (505) Deaths that are suspected of being related to abuse or neglect must be reported immediately to APS. Deaths that are the result of natural causes and/or are expected do not need to be reported to APS. If the death occurs outside of a medical facility, local law enforcement must be notified. APS will screen all incident reports and make a determination whether investigation is warranted. If the incident involves a criminal act, local law enforcement must be notified immediately. Law enforcement must be notified by the person reporting the incident. When the incident is reported to APS, if law enforcement has not been notified APS will notify law enforcement. Submitting an Incident Report regarding abuse, neglect or exploitation to the MCO and HSD does not relieve a provider of mandated reporting requirements to APS. INCIDENT REPORTING Incident Reports are submitted to HSD and to the MCO for each Consumer through the HSD Critical Incident Management website. All reports to HSD of Abuse, Neglect and Exploitation as well as the other reportable incidents; Deaths, Emergency Services, Law Enforcement Involvement and Environmental Hazards must be submitted through the website. HSD Critical Incident Reporting System_Training Guide Revised Page 5 of 24

6 CRITICAL INCIDENT REPORTING FLOW CHART The person with the most knowledge of the incident completes the Incident Report Form. 1. Report Abuse, Neglect or Exploitation (ANE) APS: Phone: (866) FAX: (505) OR CPS: FAX: (505) And HSD: 2. Report the following: Emergency services Law enforcement Environmental hazard(s) Expected and unexpected deaths HSD: If the Incident Report is for a Consumer enrolled in: DD Waiver, Medically Fragile Waiver or AIDS Waiver, FAX the incident report to the New Mexico Department of Health (DOH) Incident Management Bureau (IMB) AT: Phone (800) or FAX (800) If the Incident Report is for a Consumer receives services from: Home Health, Assisted Living Facility or a Nursing Home, FAX the Incident Report to the New Mexico Department of Health (DOH) Health Facilities Licensing and Certification (HFLC) AT: Toll Free Phone (800) or (505) or FAX (888) Report Medicaid Fraud, Waste and Abuse AT: Phone: (505) or (505) or Fax: (505) or NMMedicaidFraud@state.nm.us Report all incidents within 24 hours! In the event that an incident occurs on a weekend or holiday report the incident on the next business day. Page 6 of 24 HSD Critical Incident Reporting System_Training Guide

7 INSTRUCTIONS FOR LOGIN AND USERNAME\PASSWORD MANAGEMENT 1. HSD Critical Incident Reporting website is located at: 2. To obtain log in credentials, to reset a password or for general assistance contact Nancy and Jeanne at HSD: E mail: nancy.haas@state.nm.us and Jeanne.Cournoyer@state.nm.us Phone: (505) Each agency\mco receives a user name for each person designated to submit reports, issued by HSD. HSD manages all user names and passwords. 3. Enter your Username and Password 4. Select Log In 5. For first time users, enter your Username and temporary Password provided by HSD. a. Select Log In; once you enter your temporary password you will be prompted to change your password as seen in the screen print below. b. Enter Current Password; enter a new password of choice in New Password box and enter it again in Confirm New Password (Only requirement: password must be at least 7 characters long) c. Select Change Password d. Once a new password is successfully established you will enter the site HSD Critical Incident Reporting System_Training Guide Revised Page 7 of 24

8 INSTRUCTIONS FOR COMPLETING AND SUBMITTING REPORTS HOME PAGE The hyperlinks on the grey title bar will navigate a user to the following: >> Home Home Page also known as the Main page >> Critical Incident Reporting From Data entry form to enter Critical Incident and report Fraud >> List Critical Incident Reports Access reports submitted by your agency or MCO >> Ad Hoc Reporting Reporting module; agencies or MCOs can track and trend reports. >> Critical Incident Management Guides Link to open CriticalIncidentMgmtGuide.pdf document. Also located on the Home Page in the upper right hand corner is the following: Logged in as: displays the user id logged in this session, example: uhc.shelly Change Password: At anytime you have the option to change your own password by selecting Change Password. (See chapter Instructions For Login And Username\Password Management) Page 8 of 24 HSD Critical Incident Reporting System_Training Guide

9 CRITICAL INCIDENT REPORTING FORM The screen print below is a image of the Critical Incident Report data entry form. The yellow highlighted fields are required and must be completed in order to successfully submit the form and create an Incident Report number; however, all information is important whether required or not. HSD Critical Incident Reporting System_Training Guide Revised Page 9 of 24

10 SECTION 1-CONSUMER INFORMATION Fields denoted with an asterisks* are required. First Name*, Middle Name, Last Name:* Use the Consumer s first and last name exactly as they appear on that person s authorization paperwork. If this includes a middle name, enter it on the Incident Report Social Security Number:* Enter the Consumer's 9 digit valid Social Security Number. Example: or ); be as accurate as possible with this number. The MCO, APS and the State (HSD) track incidents for Consumer s to assist with health and safety and in developing improvement plans and if the social security number actually belongs to someone else, it becomes difficult to get good data and may violate HIPPA. Wrong Social Security Number Requires extra searching for any one following up with the incident. Can be erroneously repeated on other documents, compounding the problem. Can lead to HIPPA violations. Delays assistance Gender:* Select Consumer s gender. DOB:* Enter the Consumer s correct date of birth (Example: mm/dd/yyyy). Street Address: Enter the street address of where the Consumer is residing. If you do not provide the address you will get a call for directions. The investigator will need to know where the Consumer is and PO boxes are not helpful. Many of our rural and frontier Consumer s live in locations that do not have simple street addresses. Please provide what you have as an address and if it is not enough to find the person, include directions in the Diary section (see chapter Diary Entry). If an agency does not know where the person is, it raises questions about delivery of services. If the Consumer is homeless, enter Homeless and be prepared to answer a question about the last known address services were provided. Motels and other arrangements are addressed and it does NOT mean services cannot be provided. While this field is not mandatory for advancing the submission, it is very important information used by the MCO or APS to investigate the incident. City, County and ZIP:* Enter the City, County (select from the drop down menu) and Zip code of where the Consumer is residing. If unknown use the zip code for the agency office. Page 10 of 24 HSD Critical Incident Reporting System_Training Guide

11 Phone: Enter the Consumer s telephone number. If the Consumer does not have a phone write No Phone in the space. If you use another number to reach the person, use that number (Example: ). The investigators will need to try to reach someone and you can speed up the assistance by providing it ADLs (Consumer needs assistance with):* Check all of the boxes that the Consumer needs assistance with; if none apply select Unknown. If the agency does not have experience with the Consumer or sufficient information to complete this section check Unknown and contact the MCOs Service Coordinator to acquire the information for future reports. Verbal? Yes or No:* Means that the Consumer can communicate effectively with staff and family. It does not require that they speak English or that they speak at all. Diagnosis(es):* Enter the Consumer s Diagnoses. Refer to your copy of the Consumer s authorization paperwork to list the diagnoses. This is important data to track and the agency must have this information in client records. Contact the MCOs Service Coordinator for the information. List only three diagnoses. If there are more, add +. List of Consumer s Current Medications: * Enter the Consumer s medications. Refer to your copy of the Consumer s assessment enter the medications. See direction for Diagnoses. List no more than three. If there are more add +. Name of Doctor: Enter the full name of the doctor or enter In File Doctor Phone: Enter the office phone number of the doctor or enter In File HSD Critical Incident Reporting System_Training Guide Revised Page 11 of 24

12 SECTION 2 - DESCRIPTION OF INCIDENT Person with the most direct knowledge of the incident completes this section: Incident Type/Subcategory:* Select the Incident from the drop down menu that most accurately describes the type of incident which has occurred. Next, it is required to select the Subcategory which is different for each Incident Type. In the example below, the Incident Type selected is Abuse\Self Abuse thus displaying the list of Subcategories to choose from. Secondary Incident Type/Subcategory (optional): Enter the second incident and subcategory, when applicable, otherwise leave blank. If more than two incident types are involved with the event, please provide additional information in one of the narrative boxes in Describe what you saw and/or heard in order of occurrence: section. For questions about what type to enter review the guide or the training PowerPoint for direction. If there are still questions, contact the MCOs Service Coordinator and take their direction. Talking to the MCOs Service Coordinator DOES NOT relieve the agency of completing the report. When reporting Abuse, Neglect and Exploitation the agency must also report the incident to APS or CPS: APS: Phone (866) , FAX (505) or CPS: FAX (505) Does this incident involve alleged fraud?* Defaults to No; if the incident does involve alleged fraud, manually change selection to Yes. There will never be a case of Fraud alone, not associated with an Incident, typically fraud is associated with Exploitation. In cases of selling DME for example, the Incident should be Abuse\Self Abuse. If there is any reason to believe that fraud has been committed or that waste or abuse of Medicaid or Medicare funds are part of the incident, select Yes. Please provide sufficient information in one of the narrative boxes in Describe what you saw and/or heard in order of occurrence: section. Provide a detail description of the incident to support the allegation that fraud may have been committed. It is not necessary to prove fraud to report it. Fraud requires that Medicaid or Medicare funds are involved in the allegation. It does not include other exploitation such as theft or intimidation or harassing the Consumer to give the perpetrator property or money. Alleged Fraud is also reported via the incident form submission to the MCO who will refer to their internal Provider Integrity Units. Page 12 of 24 HSD Critical Incident Reporting System_Training Guide

13 Person responsible for individual's care at time of incident: Name, Title and Phone: Enter the name, title and phone number. If the Consumer is the responsible person, enter Self in the Title; leave Name and Phone blank. Enter Natural Supports if the person is expected to provide services to the Consumer for hours paid services that are not authorized. Did this incident occur during authorized service hours?* Select Yes or No. Specific hours do not need to be entered. The reference for this information is the Plan of Care and Schedule for Services. Was anyone else present at the time of the incident? (If yes, identify below) Select Yes or No If Yes is selected, identify them by entering the name, title or relationship and phone number in the next fields on the form. Name, Title or Relationship and Phone: If YES was selected in field Was anyone else present at the time of the incident? proceed in completing this field; if NO was selected, stop here and proceed to the next field Incident Date. Enter the name, the title or relationship and the phone number of the person(s) who was present at the time of the incident; up to three names can be entered. HSD Critical Incident Reporting System_Training Guide Revised Page 13 of 24

14 Incident Date:* Enter a valid date the incident occurred on; format of mm/dd/yyyy. The system will not allow you to proceed with an invalid, blank or future date. If you do not know the date of incident, proceed with the following the system will allow the form to be completed: o Enter date 01/01/0001 o Enter an explanation as to why the date is unknown in field Before the incident at section Describe what you saw and/or heard in order of occurrence:. Incident Time:* Enter the time the incident occurred (example: hh:mm am/pm); do not use military time. If you do not know the time of incident, enter Unknown and the system will allow the form to be completed. Date Provider Agency first had knowledge of the incident: * Enter the date reported to the agency or when MCO became aware of the incident: (Example: mm/dd/yyyy). FYI: The date of the submission of the Critical Incident Reporting form to the database has a backend date/time stamp generated automatically at submission that front end user cannot see. Incident Location:* Describe where the incident occurred (Consumer s home, grocery store, doctors office, etc). (Limited to 150 characters) Page 14 of 24 HSD Critical Incident Reporting System_Training Guide

15 Describe what you saw and/or heard in order of occurrence: There are three free text boxes with a limitation of 500 characters per box provided to document Before, During and After Incident information; all three boxes must be completed. This section is also known as the Narrative, be concise and complete when documenting. If HSD or the MCO does understand what happened, the person who completed the form will get a call to provide more information. Before the incident:* Describe what the Consumer was doing, how he/she was behaving, and what other events or interactions were occurring around the Consumer just before the incident occurred. During the incident:* Describe as accurately as possible, what actually happened to the Consumer, or what the Consumer may have reported to the person with the most immediate knowledge of the incident (i.e. physical symptoms, a fall, something missing, abuse directed at the Consumer, etc). After the incident:* Describe as accurately as possible, what actions were taken in response to the incident (i.e. did someone call 911, help the Consumer to look for something that was missing, did he/she call the office of his/her employer to ask for advice, did he/she assist the Consumer who might have fallen, was the Consumer injured or ill). Person completing Sections 1 and 2: This is the first person who will be contacted if additional information about the incident is needed. Name, Title or Relationship and Phone:* Enter the name of the person completing the report, the agency you or the person reporting the incident works for, his/her title and telephone number. HSD Critical Incident Reporting System_Training Guide Revised Page 15 of 24

16 SECTION 3 AGENCY INFORMATION: Provider:* This field will self populate with the agency logging in to the site. Incident Coordinator:* The name stated here is the name of a person assigned to manage the incident reporting functions of the agency. Questions about the incident report will go this person. Questions about the system the agency uses to manage incident reports will be directed to this person. In the case of various offices for an agency, the agency is to select the staff at the office serving the recipient identified in the incident. Office Location:* Enter the office location in the space provided. Office Phone:* Enter phone number of the agency in example format: Page 16 of 24 HSD Critical Incident Reporting System_Training Guide

17 SECTION 4 ADMINISTRATIVE INFORMATION: Program:* Select only one program the Consumer is enrolled in (only one can be selected). MCO: Select the Managed Care Organization (MCO) in which the recipient is enrolled at the time of the incident.. Which state agencies have you notified of this incident? (check all that apply)* HSD: auto populates with a check mark for all submissions once the Submit Report button is selected. APS and CPS: Select APS and or CPS if these agencies were notified. By submitting the incident, the report goes to the State (HSD) and the MCO for the recipient. The State and the MCO have access to the incident at the time of submission. APS and CPS do not have access to the website. When reporting Abuse, Neglect and Exploitation the agency must also report the incident to APS or CPS: APS: Phone (866) FAX (505) or CPS: FAX (505) Legal guardian or representative: Name: Enter the name of the Consumer s legal Guardian Name; if not applicable, leave blank. If you enter a Name, enter the Guardians Street Address, City, State and ZIP. Date of Guardianship: Enter the date of Guardianship (Example: mm/dd/yyyy). HSD Critical Incident Reporting System_Training Guide Revised Page 17 of 24

18 REPORT SUBMISSION Select the Submit Report button at the bottom of the form. When the Submit Report button is selected, either a new window will display stating the report was successfully submitted with an Incident Report # or the Critical Incident data entry form will remain open, showing the requried fields in red that need to be completed. The new window (first screeen print below) that informs the agency that the report was successfully submitted indicates the following tasks have been completed: The report is transmitted to the database and a date/time stamp is applied. The report has been assigned a unique number (Incident Report #). The State (HSD) has access to the report. The MCO for the Consumer has access to the report. The agency has access to the report. (The screen print below is an example of a successful submission; generating and Incident Report #, also known as a Case Number). (The screen print below is an example of a non successful submission; required field(s) are missing indicated in red. Enter data into all the fields in red and select the Submit Report button to try again). Page 18 of 24 HSD Critical Incident Reporting System_Training Guide

19 SEARCH FOR A CRITICAL INCIDENT REPORT Search for a submitted Critical Incident Report or confirm a report was successfully submitted: 1. Sign in to the Critical Incident Reporting System (see chapter Instructions For Login And Username\Password Management) 2. Select >> List Critical Incident Reports from the toolbar menu. 3. Any of the headers can be sorted by clicking on the header name such as Incident ID, Last Name or SSN. One mouse click sorts the list in Ascending order (Numeric or Alpha order) Two mouse click sorts the list in Descending order (Numeric or Alpha order) 4. Navigation buttons to advance to the next page are located at the bottom of the page: To advance to the next page on the list, select the next page number, To advance to next set of page numbers, select triple set of dots... To advance to the end of list, select the double arrow >> Example: Click on the Incident ID two times; this sorts the Incident ID to the last one generated. This is a quick way to search to see if a submission went through. This is helpful if there was a VPN\air card interference. HSD Critical Incident Reporting System_Training Guide Revised Page 19 of 24

20 PRINT AND FAX CRITICAL INCIDENT REPORT The CI report can be printed for APS and others for example in a format that the information can be read and faxed clearly. You must ensure that APS gets all the information needed to investigate the report. Once the report is open, the process outlined below if easy to follow. To print report already submitted, proceed with these steps: 1. Sign on to the Critical Incident Reporting System (see chapter Instructions For Login And Username\Password Management) 2. Select >> List Critical Incident Reports from the toolbar menu. 3. Choose the report that you wish to print, by clicking on the Incident ID 4. The Incident Details will appear with two options, Collapse All Expand All 5. Select Expand All (Expand the Diary Entry if that information is needed for the print or fax) Page 20 of 24 HSD Critical Incident Reporting System_Training Guide

21 6. Select the File button from your Internet toolbar to access the Print Preview menu. 7. Select Print Preview. 8. In the Print Preview window, select the following: a. Select Landscape b. Select Print size 100% c. Select Print icon to print 9. To close, select ESC on keyboard or Close icon in the upper right hand corner. HSD Critical Incident Reporting System_Training Guide Revised Page 21 of 24

22 DIARTY ENTRY INFORMATION There is a diary (aka notes ) section available on Critical Incident reports already submitted. The diary is to be utilized similar to clinical reporting, follow these guidelines: Use for brief narratives after report is submitted. Clearly written information. Written to be read by other agency staff, the MCO and the State. When additional information is necessary it can be added to the Diary at any point. When requests for information are made by the State or the MCO the diary may be used to share that information. Additional Notes: It is expected that less than 10% of reports will require diary entries. Entries are date stamped and the person making the entry is identified. Once saved, they cannot be modified or deleted, they become part of the record. PROCESS 1. Search for the Incident Report # (see chapter Search for a Critical Incident Report) 2. Go into the Incident Details 3. Click in the New Diary Entry: box and type in your information (4000 character limit). (As you type the character count down will display in the right hand corner). 4. Select the Submit button Page 22 of 24 HSD Critical Incident Reporting System_Training Guide

23 5. The Diary Entries is saved as seen in the screen print below. (Also displays the date Diary was entered and User ID) In the Incident Report Listing list for Incident ID 1641, before the diary entry, the column Diary Entries? had No; once the diary entry was added and screen refreshed, Diary Entries? changed to Yes. HSD Critical Incident Reporting System_Training Guide Revised Page 23 of 24

24 CONCLUSION If there are questions please contact: Nancy Haas Quality Bureau Medical Assistance Division Human Service Department Additional copies of the Guidelines can be printed from the website. A PowerPoint Training is available to agencies upon request by . NOTE: Upon implementation of Centennial Care there will be changes to the titles of the programs currently requiring critical incident reports as well as other changes to meet reporting requirements for the new program.. This Guide will be revised when those changes are implemented. The requirement for critical incident reporting will NOT change, only elements of how the reporting will be done. Compliance to reporting directives will continue to be expected of all agencies who serve identified populations of Medicaid recipients. Page 24 of 24 HSD Critical Incident Reporting System_Training Guide