People Inc. INCIDENT MANAGEMENT POLICY AND PROCEDURE

Transcription

1 PART 624 Form 147 People Inc. INCIDENT MANAGEMENT POLICY AND PROCEDURE Regulatory Reference: 624, 633.9, 625, ICF 42 CFR 483 and OPWDD ADM re: Implementation of the protection of People with Special Needs Act and Reforms to Incident Management (Effective June 30 th 2013). Sites: All OPWDD Programs and Services & all Non-OPWDD Programs and Services as per 625. Objective: The purpose for reporting, investigation, reviewing, and/or monitoring certain events is to enhance the quality of services provided to persons, to protect people from harm, and to ensure that people are free from abuse and neglect. A primary function of reporting certain events and situations is to enable the governing body, management and supervisory staff to be aware and take corrective action, and minimize the potential for recurrence of similar situations. Prompt reporting ensures that any immediate steps are taken to protect people from being exposed to similar risks. This policy outlines the process whereby situations that endanger a person s well-being while under People Inc. s auspices are reported, investigated, and reviewed. Protective, corrective, and remedial actions will be determined as necessary based on reports, investigation and review. Please Note: Regulatory References are to Emergency Regulations dated 6/30/13. Incident Categories & Classifications EFFECTIVE 6/30/2013 Category REPORTABLE INCIDENT Abuse and Neglect (by Custodians) REPORTABLE INCIDENT Significant Incidents Classification 1 Physical Abuse 2 Sexual Abuse 3 Psychological Abuse 4 Deliberate inappropriate use of restraints 5 Use of aversive conditioning 6 Obstruction of reports of reportable incidents 7 Unlawful use or administration of a controlled substance 8 Neglect 1 Conduct between people receiving services 2 Other mistreatment 3 Seclusion 4 Unauthorized use of time-out 5 Medication error with adverse effect 6 Inappropriate use of restraints 7 Missing person 8 Choking, with known risk 9 Self-abusive behavior with injury 1

2 LECT REPORTABLE INCIDENTS OF ABUSE OR NEGLECT 1. Physical Abuse - Conduct by a custodian intentionally or recklessly causing, by physical contact, physical injury or serious or protracted impairment of the physical, mental, or emotional condition of the individual receiving services, or causing the likelihood of such injury or impairment. Such conduct may include, but shall not be limited to: slapping, hitting, kicking, biting, choking, smothering, shoving, dragging, throwing, punching, shaking, burning, cutting, or the use of corporal punishment. Physical abuse shall not include reasonable emergency interventions necessary to protect the safety of any party. 2. Sexual Abuse - Any conduct by a custodian that subjects a person receiving services to any offense defined in article 130 or section , , or of the penal law, or any conduct or communication by such custodian that allows, permits, uses, or encourages a person receiving services to engage in any act described in articles 230 or 263 of the penal law; and/or any sexual contact between an individual receiving services and a custodian of the program or facility which provides services to that individual whether or not the sexual contact would constitute a crime. However, if the individual receiving services is married to the custodian the sexual contact shall not be considered sexual abuse. Further, for purposes of this subparagraph only, a person with a developmental disability who is or was receiving services and is also an employee or volunteer of an agency shall not be considered a custodian if he or she has sexual contact with another individual receiving services who is a consenting adult who has consented to such contact. 3. Psychological Abuse - Any verbal or nonverbal conduct that may cause significant emotional distress to an individual receiving services. Examples include, but are not limited to, taunts, derogatory comments or ridicule, intimidation, threats, or the display of a weapon or other object that could reasonably be perceived by an individual receiving services as a means for infliction of pain or injury, in a manner that constitutes a threat of physical pain or injury. In order for a case of psychological abuse to be substantiated after it has been reported, the conduct must be shown to intentionally or recklessly cause, or be likely to cause, a substantial diminution of the emotional, social or behavioral development or condition of the individual receiving services. Evidence of such an effect must be supported by a clinical assessment performed by a physician, psychologist, psychiatric nurse practitioner, licensed clinical or master social worker or licensed mental health counselor. 4. Deliberate Inappropriate Use of Restraints - The use of a restraint when the technique that is used, the amount of force that is used, or the situation in which the restraint is used is deliberately inconsistent with an individual s plan of services (e.g. individualized service plan (ISP) or a habilitation plan), or behavior support plan, generally accepted treatment practices, and/or applicable federal or state laws, regulations or policies, except when the restraint is used as a reasonable emergency intervention to prevent imminent risk of harm to a person receiving services or to any other party. For purposes of this paragraph, a restraint shall include the use of any manual, pharmacological, or mechanical measure or device to immobilize or limit the ability of a person receiving services to freely move his or her arms, legs or body. 5. Use of Aversive Conditioning - The application of a physical stimulus that is intended to induce pain or discomfort in order to modify or change the behavior of a person receiving services. Aversive conditioning may include, but is not limited to, the use of physical stimuli such as noxious odors, noxious tastes, blindfolds, and the withholding of meals and the provision of substitute foods in an unpalatable form. The use of aversive conditioning is prohibited by OPWDD. 2

3 6. Obstruction of Reports of Reportable Incidents - Conduct by a custodian that impedes the discovery, reporting, or investigation of the treatment of a service recipient by falsifying records related to the safety, treatment, or supervision of an individual receiving services; actively persuading a custodian or other mandated reporter from making a report of a reportable incident to the statewide vulnerable persons' central register (VPCR) or OPWDD with the intent to suppress the reporting of the investigation of such incident; intentionally making a false statement, or intentionally withholding material information during an investigation into such a report; intentional failure of a supervisor or manager to act upon such a report in accordance with OPWDD regulations, policies or procedures; or, for a custodian, failing to report a reportable incident upon discovery. 7. Unlawful Use or Administration of a Controlled Substance - Any administration by a custodian to a service recipient of a controlled substance without a prescription, or other medication not approved for any use by the federal food and drug administration. It also shall include a custodian unlawfully using or distributing a controlled substance at the workplace or while on duty. 8. Neglect - Any action, inaction, or lack of attention that breaches a custodian's duty and that results in or is likely to result in physical injury or serious or protracted impairment of the physical, mental, or emotional condition of a service recipient. Neglect shall include, but is not limited to: failure to provide proper supervision, including a lack of proper supervision that results in conduct between persons receiving services that would constitute abuse if committed by a custodian; failure to provide adequate food, clothing, shelter, or medical, dental, optometric or surgical care, consistent with Parts 633, 635, and 686, of this Title, and provided that the agency has reasonable access to the provision of such services and that necessary consents to any such medical, dental, optometric, or surgical treatment have been sought and obtained from the appropriate parties; or failure to provide access to educational instruction, by a custodian with a duty to ensure that an individual receives access to such instruction in accordance with the provisions of part one of article 65 of the education law and/or the individual's individualized education program. 3

4 REPORTABLE INCIDENTS SIGNIFICANT INCIDENTS 1. Conduct Between Persons Receiving Services - Conduct between persons receiving services that would constitute abuse as described in paragraphs (1) through (7) of this subdivision if committed by a custodian, except sexual activity involving adults who are capable of consenting and consent to the activity 2. Other Mistreatment - Conduct on the part of a custodian, that is inconsistent with the individual s plan of services, generally accepted treatment practices, and/or applicable federal or state laws, regulations or policies, and which impairs or creates a reasonably foreseeable potential to impair the health, safety, or welfare of an individual receiving services 3. Seclusion -The placement of an individual receiving services in a room or area from which he or she cannot, or perceives that he or she cannot, leave at will. OPWDD prohibits the use of seclusion; 4. Unauthorized Use of Time-Out - The use of a procedure in which a person receiving services is removed from regular programming and isolated in a room or area for the convenience of a custodian, or as a substitute for programming. 5. Medication Error with Adverse Effect - The administration of a prescribed or over-the-counter medication, which is inconsistent with a prescription or order issued for a service recipient by a licensed, qualified health care practitioner, and which has an adverse effect on an individual receiving services. For purposes of this clause, "adverse effect" shall mean the unanticipated and undesirable side effect from the administration of a particular medication which unfavorably affects the wellbeing of a person receiving services 6. Inappropriate Use of Restraints - The use of a restraint when the technique that is used, the amount of force that is used, or the situation in which the restraint is used is inconsistent with an individual s plan of services (including a behavior support plan), generally accepted treatment practices, and/or applicable federal or state laws, regulations or policies. For the purposes of this subdivision, a "restraint" shall include the use of any manual, pharmacological or mechanical measure or device to immobilize or limit the ability of a person receiving services to freely move his or her arms, legs or body. 7. Missing Person - The unexpected absence of an individual receiving services that based on the person's history and current condition exposes him or her to risk of injury. 8. Choking, with Known Risk - Partial or complete blockage of the upper airway by an inhaled or swallowed foreign body, including food, that leads to a partial or complete inability to breathe, involving an individual with a known risk for choking and a written directive addressing that risk 9. Self-Abusive Behavior, with Injury - A self-inflicted injury to an individual receiving services that requires medical care beyond first aid. 4

5 REPORTABLE INCIDENT ABUSE AND NEGLECT (By Custodians) Person Responsible: Custodian Situation: Custodian observes a situation that may be abusive: Responsibility: All custodians are responsible for ensuring the safety and well-being of people receiving services. Action: Custodian will immediately intervene to stop the abuse and protect the person by: Custodian observes or discovers a situation of abuse Custodian observes or discovers a situation which they are unsure meets the criteria for an allegation of abuse, but in which they feel an individual s well-being may be jeopardize: Removing the party who may be abusing the individual or bringing the individual to another area that is safe. If the potentially abusive party is another custodian, this will be initiated by telling the custodian to leave the immediate environment while you take over. The custodian who is asked to withdraw for this reason is to comply unless the safety of the person precludes this. It may be necessary for the custodian who discovers the alleged abuse to obtain the support of management staff or in extreme cases, law enforcement in order to effect this protection. In addition to the above, custodian will immediately contact: 1. Their Management Chain 2. QI staff: (716) (716) Justice during business hours after business hours In addition to the above, custodian will immediately contact: 1. Their Management Chain 2. QI staff: (716) (716) In any of the above situations, to the extent permitted by law, staff will refrain from discussing the incident with anyone except their supervisor and/or QI staff responsible for receiving the report. Custodian must not compromise the investigation of the incident, or violate any applicable privacy or confidentiality requirements. 5

6 Situation: When there is any question or possibility that an incident may have resulted in an injury or a person s health may be compromised Action: Custodian will ensure immediate medical follow-up by: Consulting the RN or On-Call RN and/or taking the person to their physician, ER or hospital to obtain evaluation/treatment depending on the severity of the situation. 911 should be called in situations of serious injury or life threatening circumstances. If the RN or On-Call RN provides direction related to an injury or medical condition, the custodian will follow these directions. If there is a problem which would prevent these directions from being followed (e.g. lack of staffing, etc.), custodian will notify the management chain to address the situation. When suspicious bruises or injuries are discovered When there is a need to photograph injuries Preserving Evidence In Cases of Sexual Assault or Rape Staff will describe the injuries noted and consult with the nurse and supervisor when the need for a body check is indicated. The body check and documentation on the Body Check Form may be completed by the nurse or a medical practitioner. At times the custodian may be requested to carry out a body check. When this occurs, the custodian will explain the need for the body check to the person and request the person s permission to do the check. The Body Check Form is currently located on the Agency Intranet, Nursing web page. There is also a Body Check Form available via Therap (Individual tab GER Injury) for staff completion and (Health tab Skin/Wound) for nursing completion. If custodians are requested to photograph suspicious injuries, the staff member will explain the reason for this to the person and request the person s permission. When there is physical evidence related to an Allegation of Abuse (or other incident), the custodian will secure and preserve it whenever possible. Custodian ensures that the person is taken to the hospital for evaluation prior to hygiene care or change of clothing. If the alleged victim is an adult they must be taken for evaluation to Erie County Medical Center. If the incident involves a child the evaluation must be done at Women and Children s Hospital of Buffalo. Adult women may utilize either hospital. 6

7 REPORTABLE INCIDENTS OF ABUSE AND NEGLECT & REPORTABLE INCIDENTS - SIGNIFICANT INCIDENTS Protection of Individual Receiving Service Senior Residential Supervisor (SRS)/ Senior Program Manager (SPM) Ensures the safety of the individual receiving services. Upon receiving a report of an Allegation of Abuse, Neglect or Significant Incident reviews the actions taken to protect the person s safety and well-being and takes additional actions necessary based on the seriousness of the situation including, when indicated: Removal, reassignment, relocation or suspension of the alleged abuser. Increasing the degree of supervision of the alleged abuser (to be described specifically per incident.) Provision of counseling to the alleged victim. Provision of increased training to the alleged abuser and custodian pertinent to the prevention and remediation of abuse. Increasing supervision and providing additional support to restore a secure environment to the affected staff and persons in the facility. Removal or relocation of the person, consistent with his or her developmental needs (or any court order applicable to the person) when it is determined that there is a risk to such individual if he or she remains in the program or location. Provision of comfort/counsel to the individual and to other persons in the facility. Ensures that all actions described in custodian responsibilities are carried out by staff or the supervisor themselves to ensure the person is protected, evaluated and treated, if necessary. Ensures any other action necessary to preserve evidence, appropriately document and report the incident. Internal Agency Notification of Incident Senior Residential Supervisor (SRS)/ Senior Program Manager (SPM) Notifies Management Chain of the incident immediately after assuring the person is safe. 7

8 Senior Residential Supervisor (SRS)/ Senior Program Manager (SPM) (cont.) Consults with Residential Director/Program Director for necessary protective measures. Notifies QI Management Notifies QI Administrative Staff, as soon as possible, but no later than 24 hours Communicates protective actions taken to the custodian, informing the custodian involved of administrative leave when this decision has been made Does not explain the specifics of the allegation to the employee Notifies individuals and custodian who have regular contact with the involved custodian, only providing the information that is necessary (e.g. employee will be absent, employee will be changing shifts, how much oversight is required when the protective action involves the employee always working with another custodian, etc.) Residential Director/Program Director Ensures the safety of the individual receiving services. Ensures necessary actions have been completed. Notifies QI Management Notifies IRC via Agency Incident Notification Notifies Senior Management as necessary for serious incidents Internal Agency Notification of Incident via Therap Senior Residential Supervisor (SRS)/ Senior Program Manager (SPM) Ensures GER completion in Therap Ensures OPWDD 147 Form is complete Refer to People Inc. Therap GER Incident Process for additional information and procedures related to completing GER s in Therap. External Notification of Incident via IRMA QI Administrative Staff Enters information from the 147 immediately (within 24 hours) into IRMA 8

9 External Notification of Incident for Justice Center, OPWDD or Incident Management Unit Senior Residential Supervisor (SRS)/ Senior Program Manager (SPM) Upon discovery notifies the Justice Center for all Reportable Abuse & Neglect, and Reportable Significant Notifies OPWDD during normal business Notifies the OPWDD Incident Management Unit (IMU) during off business hours via ([email protected]) or hotline , depending on the severity of the incident If the incident is serious you must call the hotline #. External Notification for NYS Child Abuse and Maltreatment Reporting Center When the allegation is of abuse to a child under the age of 18 and does not involve a custodian (e.g. parent hits child in IRA): Notifies the NYS Child Abuse and Maltreatment Reporting Center Refer to Mandated Reporting of Suspected Child Abuse Pg. 13 External Notification for Adult Protective Services (APS) APS Involvement: There is a memorandum of understanding indicating that for individuals receiving OPWDD Services, the OPWDD Agency is required to conduct an investigation. When there is a serious risk to the individual and problems with access to or protection of the individual, QI staff should be contacted and discussion with DDSO representatives will occur. 9

10 External Notification for Police Department Residential Director/Program Director When the allegation of abuse also involves a possible crime committed against an individual (including all allegations of Physical Abuse, Sexual Abuse, etc. involving a crime): Informs the QI Department QI Staff Contacts Police Department where crime allegedly occurred. Ensures documentation of dates, times of contact and name of police contacts are entered into Therap and IRMA. Notification to Social Service Worker / Medicaid Service Coordinator Senior Residential Supervisor (SRS)/ Senior Program Manager (SPM) Notifies Social Service Worker (SSW) or Medicaid Service Coordinator (MSC) of the incident within 24 hours The notification must include a description of immediate protections. (This notification can be verbal.) Provides written information identifying investigative conclusions (including the findings of an allegation of abuse or neglect) and recommendations pertaining to the individual's care, protection, and treatment within 10 days following completion of the investigation The information provided must exclude information that directly or indirectly identifies agency employees, consultants, contractors, volunteers, or other individuals receiving services. In addition to the above, if the IRC review results in additional findings, conclusions, or recommendations regarding the individual's care, protection, and/or treatment, this information must be provided to the SSW/MSC, in written form, within 3 weeks following committee review. If the SSW/MSC is identified as the subject of a report of an allegation of abuse or neglect or as a witness to a reportable incident or occurrence, the agency shall not provide information to that party. In such a case, notifications and written information referred to must be provided to the SSW/MSC supervisor or the administrator of the agency providing service coordination in lieu of the SSW/MSC. The above also applies to Qualified Intellectual Disability Professional (QIDP) in ICF residences. 10

11 Notification to Family Senior Residential Supervisor (SRS)/ Senior Program Manager (SPM) Notifies Guardian, family member and/or correspondent within 24 hours. When the person is considered a capable adult, notifications to family will occur only if the person approves of this contact. Informs the person s parent, guardian or correspondent/advocate that s/he may request information on the status and/or resolution of Reportable Incidents and Occurrences, unless the person is a capable adult and objects to such information being provided or the alleged abuser is one of the aforementioned parties. Offers a meeting with the CEO/Designee to further discuss the incident or allegation of abuse Offers to provide information on the status and/or findings of the incident for allegations of abuse and neglect Notifies other programs the person attends. Notification consists of information necessary for the program s protection and treatment of the person e.g., An allegation of psychological abuse has been reported involving A.B. at his residence. It is being investigated by our agency. He doesn t appear to be upset at this point, but please inform us if there is any behavior or communication which may relate to the allegation. Notifies the Guardian, family member and/or correspondent after the completion of the investigation and reports any steps taken to protect the individual. If the notified party requests any further information this will be documented and referred to the QI Department. Documents all notifications, on the GER Notification Table in Therap. Including names, dates, notified by, and method of notifications i.e. phone etc. Refer to People Inc. Therap GER Incident Process for additional information and procedures related to completing GER s in Therap. External Notification of Incident to Mental Hygiene Legal Services (MHLS) Residential/Program Administrative Staff Ensures any person who resides in a certified residence the 147 is sent to MHLS within 3 working days. 11

12 Residential/Program Administrative Staff In Day Hab programs and other non-residential facilities it is the responsibility of that program to send the 147 to MHLS for persons who reside in a certified residence regardless of the Agency managing the residence. Incident Closure Residential Director/Program Director Upon the closure of Incident at IRC provides response(s) to recommendation of IRC. The plan of responses will include which staff by titles will take specific actions by specific dates. This plan will be authorized in writing by the Director as the CEO s designee. Senior Residential Supervisor (SRS)/ Senior Program Manager (SPM) Ensures notification to Social Service Worker/Medicaid Service Coordinator as outlined above Ensures notification to Guardian, family member and/or correspondence as outlined above QI Administrative Staff Reviews IRC minutes and enters closure of incidents into IRMA 12

13 Mandated Reporting of Suspected Child Abuse Agency Process Regulatory Reference: Informational Letter Transmitted: 07-OCFS-INF-07 18NYCRR (C), (C), 441.8(C) Legislation requires that mandated reporters (People Inc. staff) must make reports to the Central Child Abuse Registry directly when an allegation of abuse involving a child is observed or discovered. When a custodian witnesses or discovers an allegation of abuse involving a person under the auspices of a certified program the requirement is to notify the Justice Center and not the NYS Child Abuse and Maltreatment reporting center. For all other cases custodians are mandated reporters and should notify the Child Abuse registry through the numbers given below: While it is a requirement for staff to make this call directly and not seek the prior notification or approval of their supervisor, it is still important for staff to contact supervisory staff. It is preferable that supervisory staff be involved with the reporting process, just as agency policy requires in allegation of abuse situations with adults. It is essential that protective measures be put in place which must be discussed with supervisory staff as soon as possible. Event: Action: Staff become aware of an allegation of abuse involving a child. Staff provide immediate action to protect the child involved if possible Staff notify Supervisory Personnel of allegation and action taken and call: NYS Child Abuse and Maltreatment Reporting Center Information provided should be given objectively and describe the areas on the form LDS2221A. (When the situation allows this form should be filled out prior to calling the reporting center). Staff contact management staff and inform them of the report which they provided and response by the Child Protection Specialist contacted. The LDSS 2221A form is completed and sent to the DSS Office of Children and Family Services in the county where the child resides: Erie County DSS 478 Main Street Room 425 Buffalo, N.Y Tel#: Chautauqua Co. DSS S.C.O.B. 110 E. 4 th Street Jamestown, N.Y Tel#: Dunkirk Office: Niagara Co DSS th Street PO Box 865 Niagara Falls, N.Y Tel#:

14 SERIOUS NOTABLE OCCURRENCES Serious Notable Occurrences Part Injury (that requires hospitalization) 2 Unauthorized absence 3 Death 4 Choking, with no known risk Theft or Financial Exploitation (>$100 or Credit/Debit 5 Card) 6 Sensitive Situation 7 ICF Violations Injury Any injury that requires hospitalization. Unauthorized absence The unexpected or unauthorized absence of a person after formal search procedures have been initiated by Agency. Death Immediate notification of all deaths must be reported to the Justice Center Death Reporting within 24 hours of occurrence or discovery. QI must be notified immediately of all deaths. Choking, with no known risk For the purposes of this paragraph, partial or complete blockage of the upper airway by an inhaled or swallowed foreign body, including food, that leads to a partial or complete inability to breathe, other than a "reportable" choking, with known risk, incident (see subparagraph 624.3(b)(9)(iv) of this Part), involving an individual with a known risk for choking and a written directive addressing that risk. Any choking with no known risk event is considered a serious notable occurrence. Theft and Financial Exploitation - Any suspected theft of a service recipient's personal property (including personal funds or belongings) or financial exploitation, involving values of more than $ or involve a credit, debit, or public benefit card, regardless of any specific amount involved, or a pattern of theft is evident. Sensitive Situation Those situations involving a person receiving services that do not meet the criteria of the definitions in paragraphs (1) (5) of this subdivision or the definitions of reportable incidents as defined in section of this Part, that may be of a delicate nature to the agency, and are reported to ensure awareness of the circumstances. Sensitive situations shall be defined in agency policies and procedures, and shall include, but not be limited to, possible criminal acts committed by an individual receiving services. Sensitive situations are serious notable occurrences. ICF Violation Events and situations concerning residents of Intermediate Care Facilities (ICFs) that are identified as violations in federal regulation applicable to ICFs and do not meet the definitions of reportable incidents as specified in section of this Part or other notable occurrences as specified in this section. ICF violations are serious notable occurrences. 14

15 SERIOUS NOTABLE OCCURRENCES Staff Notifies Management Chain for all Serious Notable Occurrences Completes GER in Therap or Agency Incident Report (Appendix A) if Therap is unavailable. Injuries Staff Contact s Emergency Medical Services (911) immediately for all life threatening emergencies. Immediately safeguards the individual by following Basic First Aid Training. Notifies the RN or On-Call RN of the injury Follows the RN or On-Call RN directions (e.g. contact the individuals physician, transport to nearest Urgent Care or ER etc.) Notifies Management Chain of the injury, RN or On-Call RN directions and/or if there is a problem which would prevent these directions from being followed (e.g. lack of staffing, etc.). Transports the individual as necessary Completes GER in Therap or Agency Incident Report (Appendix A) if Therap is unavailable. Senior Residential Supervisor (SRS)/ Senior Program Manager (SPM) Instructs staff as necessary for all Serious Notable Occurrences Notifies Management Chain as soon as possible Notifies Guardian, family member and/or correspondence Notifies Social Service Worker /Medicaid Service Coordinator Notifies other programs as necessary Reviews and completes GER in Therap or Agency Incident Report (Appendix A). Completes the 147 in Therap Notifies QI Department as soon as possible 15

16 Notifies QI Administrative Staff as soon as possible but no later than 24 hours for IRMA entry Reports to the site or location of individual Asks the individual for permission to take pictures of the injury Takes pictures of the injury requiring medical or dental treatment No pictures will be taken of private areas of the body. Sends pictures electronically to QI and/or uploads into Therap GER as an attachment. Deletes pictures from digital camera immediately after sending to QI or uploading into Therap External Notification of Incident for OPWDD or Incident Management Unit Senior Residential Supervisor (SRS)/ Senior Program Manager (SPM) Notifies OPWDD during normal business Notifies the OPWDD Incident Management Unit (IMU) during off business hours via ([email protected]) or hotline , depending on the severity of the incident If the incident is serious you must call the hotline #. Theft or Financial Exploitation To ensure a consistent approach regarding missing program and/or individual funds or property the following procedures are to be followed. Senior Residential Supervisor (SRS)/ Senior Program Manager (SPM) The Business Office and Assistant Controller will be notified. If there is evidence of a theft police will be immediately notified. Residential Director/Program Director During the course of the investigation the respective director will be kept apprised of the status of the investigation. 16

17 Serious Notable Occurrence Residential Director/Program Director Ensures the safety of the individual receiving services for all Serious Notable Occurrences. Ensures necessary actions have been completed. Notifies QI Management Notifies IRC via Agency Incident Notification QI Administrative Staff Immediately enters information from the 147 into IRMA within 24 hours 17

18 MINOR NOTABLE OCCURANCES Minor Notable Occurrences Part Injury (requiring medical or dental treatment) 2 Theft or Financial Exploitation (>$15 but <$100) Injury - Any suspected or confirmed harm, hurt, or damage to an individual receiving services, caused by an act of that individual or another, whether or not by accident, and whether or not the cause can be identified, which results in an individual requiring medical or dental treatment (e.g. positive x-ray finding, received medication etc.) by a physician, dentist, physician's assistant, or nurse practitioner, and such treatment is more than first aid. (Illness in itself shall not be reported as an injury or any other type of incident or occurrence.) Theft and Financial Exploitation - Any suspected theft of a service recipient's personal property (including personal funds or belongings) or financial exploitation, involving values of more than $15.00 and less than or equal to $100.00, that does not involve a credit, debit, or public benefit card, and that is an isolated event. 18

19 MINOR NOTABLE OCCURRENCES Staff Notifies Management Chain for all Minor Notable Occurrences Completes GER in Therap or Agency Incident Report (Appendix A) if Therap is unavailable. Injuries Staff Contact s Emergency Medical Services (911) immediately for all life threatening emergencies. Immediately safeguards the individual by following Basic First Aid Training. Notifies the RN or On-Call RN of the injury Follows the RN or On-Call RN directions (e.g. contact the individuals physician, transport to nearest Urgent Care or ER etc.) Notifies Management Chain of the injury, RN or On-Call RN directions and/or if there is a problem which would prevent these directions from being followed (e.g. lack of staffing, etc.). Transports the individual as necessary Completes GER in Therap or Agency Incident Report (Appendix A) if Therap is unavailable. Senior Residential Supervisor (SRS)/ Senior Program Manager (SPM) Instructs staff as necessary for all Minor Notable Occurrences Notifies Management Chain as soon as possible Notifies Guardian, family member and/or correspondence Notifies Social Service Worker /Medicaid Service Coordinator Notifies other programs as necessary Reviews and completes GER in Therap or Agency Incident Report (Appendix A) Completes the 147 in Therap Notifies QI Department as soon as possible 19

20 Notifies QI Administrative Staff as soon as possible but no later than 48 hours for IRMA entry Reports to the site or location of individual Asks the individual for permission to take pictures of the injury Takes pictures of the injury requiring medical or dental treatment No pictures will be taken of private areas of the body. Sends pictures electronically to QI and/or uploads into Therap GER as an attachment. Deletes pictures from digital camera immediately after sending to QI or uploading into Therap External Notification of Incident via IRMA QI Administrative Staff Immediately enters information from the 147 into IRMA within 48 hours Theft or Financial Exploitation To ensure a consistent approach regarding missing program and/or individual funds or property the following procedures are to be followed. External Notification of Incident for OPWDD or Incident Management Unit Senior Residential Supervisor (SRS)/ Senior Program Manager (SPM) Notifies OPWDD during normal business Notifies the OPWDD Incident Management Unit (IMU) during off business hours via ([email protected]) or hotline , depending on the severity of the incident If the incident is serious you must call the hotline #. Senior Residential Supervisor (SRS)/ Senior Program Manager (SPM) The Business Office and Assistant Controller will be notified. If there is evidence of a theft police will be immediately notified. 20

21 Residential Director/Program Director During the course of the investigation the respective director will be kept apprised of the status of the investigation. Minor Notable Occurrence Residential Director/Program Director Ensures the safety of the individual receiving services for all Minor Notable Occurrences. Ensures necessary actions have been completed. Notifies QI Management Notifies Subcommittee via QI Administrative Staff Immediately enters information from the 147 into IRMA within 48 hours 21

22 INTERNAL AGENCY INCIDENTS 1 Injury (may or may not require basic first aid) Internal Agency Incidents 2 Pressure Wound (stage 1 & 2) 3 Missing Money/Theft or Financial Exploitation ($15 or less) 4 Fall 5 Near Fall 6 Other Internal Agency Incidents These are situations that do not rise to allegations that need reporting to the Justice Center or OPWDD. The QI Department and program will determine if a situation falls in this category, and who will investigate. Injury An injury which may or may not result in an individual requiring basic first aid. Pressure Wound (stage 1 or 2) A reddened area in the skin, that may be warm to the touch, a blister that may form or break. An area of tissue that is open and difficult/slow to heal due to constant pressure. Missing Money/Theft Any suspected theft of a service recipient's personal property (including personal funds or belongings) or financial exploitation, involving values of $15.00 or less, that does not involve a credit, debit, or public benefit card, and that is an isolated event. Fall Unintentionally coming to rest on the ground, floor, or other lower level with or without injury. Near Fall Any time an individual unintentionally slips, trips or losses balance where the person starts to fall but is able to stop or prevent the fall by themselves or the support from staff. 22

23 ALLEGATIONS OF ABUSE AND NEGLECT AND SIGNIFICANT INCIDENTS FALSE REPORTING CLINCIAL PLANS When an individual has a behavior pattern of making frequent unsubstantiated accusations of abuse: Management Responsibilities: Senior Residential Supervisor/ Senior Program Manager Ensure that the Support Team discusses the need for a program to orient a person to reality or encourage truth telling when a person demonstrates a potential need for this. When a person has demonstrated that they are a chronic accuser, the Team may consider a procedure that creates a different mechanism for reviewing these reports. A program which allows the agency to by-pass normal reporting procedures can only be put in place when: The person has made a significant number of allegations of abuse the overwhelming majority of which have been disconfirmed and in which the investigation reflects a lack of credibility on the part of the person. The program dictates the normal reporting and investigation of allegations for any allegations which do not fit the criteria established for making a determination that the report is false. The program includes steps to conduct a preliminary investigation to ascertain whether there is or is not a basis for credibility of the report. The program is reviewed and approved by the agency Human Rights Committee. Once Approved: The person s pattern of allegations is reviewed by the Agency HRC on a quarterly basis. If a Clinical False Reporting Plan is approved and the individual reports an allegation, the allegation needs to be reported to the Justice Center. QI needs to be notified immediately. QI will send an investigator out immediately. If the investigator is able to Disconfirm the allegation within 24 hours, then program does not need to complete any paperwork. If the allegation is not Disconfirmed within 24 hours then program proceeds with required paperwork. 23

24 PROCEDURE FOR COMPLYING WITH REQUESTS FOR INCIDENT INFORMATION There are time frames for providing information for qualified parties under the Jonathan s Law Regulations. In order to ensure these time frames are met, the following process will be followed: 147 s When a copy of the incident report is requested by a qualified party (Guardians, Parents, Adult Children and spouses of People receiving service as well as Siblings and Active Correspondents) the Residential/Program Management staff will provide a copy of the 147 to the QI Office requesting that the 147 be redacted. QI staff will redact the 147 to remove information tending to identify other parties. The 147 will be reviewed, redacted and returned to the program management staff along with a letter explaining that the incident is yet to be investigated. Program staff will keep documentation of the 147 being sent to the qualified party who requested it. Investigations Qualified parties (Guardians, Parents, Adult Children and spouses of People receiving services with the exception of incidents in which they are alleged to be perpetrators or when the person receiving service is a capable adult who does not wish for this information to be provided) who request investigations for Reportable Incidents and Occurrences will be told that such requests must be provided in writing to the Agency QI office at 280 Spindrift in Williamsville, N.Y. Residential/Program Management Staff will also note the request. Redacted investigation reports will be provided within 21 days of closure by the Agency IRC. When a request is made by an eligible party after the incident has been closed and is within the law s required time frames, it will be provided with 21 days of the receipt of the request. And provide the information to QI staff with the party s name, relationship and address. The Agency QI Office will redact the Investigation materials and return them to the Residential/Program Department for mailing to the qualified party. A record of the provision of the report will be maintained by the program Department. 24

25 PART 625 Form 150 Events & Situations That Are Not Under The Auspices Of An Agency EFFECTIVE 6/30/2013 Category EVENTS & SITUATIONS 1 Physical Abuse 2 Sexual Abuse 3 Emotional Abuse 4 Active neglect 5 Passive neglect 6 Self neglect 7 Financial exploitation 8 Death 9 Other Classification Physical Abuse - The non-accidental use of force that results in bodily injury, pain or impairment, including but not limited to, being slapped, burned, cut, bruised or improperly physically restrained Sexual Abuse - Non-consensual sexual contact of any kind, including but not limited to, forcing sexual contact or forcing sex with a third party. Emotional Abuse - The willful infliction of mental or emotional anguish by threat, humiliation, intimidation, or other abusive conduct, including but not limited to, frightening or isolating an adult Active Neglect - The willful failure by the caregiver to fulfill the care-taking functions and responsibilities assumed by the caregiver, including but not limited to, abandonment, willful deprivation of food, water, heat, clean clothing and bedding, eyeglasses or dentures, or health related services. Passive Neglect - The non-willful failure of a caregiver to fulfill care-taking functions and responsibilities assumed by the caregiver, including but not limited to, abandonment or denial of food or health related services because of inadequate caregiver knowledge, infirmity, or disputing the value of prescribed services. Self Neglect - An adult s inability, due to physical and/or mental impairments, to perform tasks essential to caring for oneself, including but not limited to, providing essential food, clothing, shelter, and medical care; obtaining goods and services necessary to maintain physical health, mental health, emotional well-being, and general safety; or managing financial affairs. Financial Exploitation - The use of an adult s funds, property, or resources by another individual, including but not limited to, fraud, false pretenses, embezzlement, conspiracy, forgery, falsifying records, coerced property transfers, or denial of access to assets. Death - The end of life, expected or unexpected, regardless of cause. 25

26 NON-CERTIFIED PROGRAMS MEDICAIDE SERVICE COORDINATION, COMMUNITY HABILITATION, PCSS, SEMP, PREVOC, WAIVER RESPITE, HOURLY, FSS etc. When any of the following incident types occur in a non-certified Agency operated program: Reportable Incidents of Abuse and Neglect Reportable Significant Incidents Serious Notable Occurrences other than Deaths o Deaths which occur under a certified programs auspices (within 30 days of the death) must be reported to the Justice Center. Minor Notable Occurrences in certified and non-certified settings may be reported to OPWDD through IRMA. If a custodian is involved in the allegation in a non-certified site, follow the 624 Regulations and procedures for completing the 147 form. The Justice Center Notification is not necessary. OPWDD notification is required: (Selena Hughes during business hours) (IMU during weekends and Holidays) Events/Situations Not Under Auspices of Agency Events not under the auspices of agency programs under 625 regulations (schools, hospitals, medical offices, etc.) 150 Form is completed by Supervisor following the responsible program hierarchy: Residential Facility Certified Day Program MSC or PCSS HCBS Waiver Services FSS, ISS, and/or Article 16 Clinic 150 Form is then sent to QI and Sub-Committee for review. 26

27 EVENTS & SITUATIONS THAT ARE NOT UNDER THE AUSPICES OF AN AGENCY Staff Notifies Management Chain for all Events & Situations Completes GER in Therap or Agency Incident Report (Appendix A) if Therap is unavailable. Events & Situations with Injuries Staff Contact s Emergency Medical Services (911) immediately for all life threatening emergencies. Immediately safeguards the individual by following Basic First Aid Training. Notifies the RN or On-Call RN of the injury (if applicable) Follows the RN or On-Call RN directions (e.g. contact the individuals physician, transport to nearest Urgent Care or ER etc.) (if applicable) Notifies Management Chain of the injury, RN or On-Call RN directions and/or if there is a problem which would prevent these directions from being followed (e.g. lack of staffing, etc.). (if applicable) Transports the individual as necessary Completes GER in Therap or Agency Incident Report (Appendix A) if Therap is unavailable. Senior Residential Supervisor (SRS)/ Senior Program Manager (SPM) Instructs staff as necessary for all Events & Situations Notifies Management Chain as soon as possible Notifies Guardian, family member and/or correspondence Notifies Social Service Worker /Medicaid Service Coordinator Notifies other programs as necessary Reviews and completes GER in Therap or Agency Incident Report (Appendix A) Completes the 150 and uploads into Therap Notifies QI Department as soon as possible 27

28 Notifies QI Administrative Staff as soon as possible but no later than 48 hours for IRMA entry Reports to the site or location of individual Asks the individual for permission to take pictures of the injury Takes pictures of the injury requiring medical or dental treatment No pictures will be taken of private areas of the body. Sends pictures electronically to QI and/or uploads into Therap GER as an attachment. Deletes pictures from digital camera immediately after sending to QI or uploading into Therap External Notification of Incident for OPWDD or Incident Management Unit Senior Residential Supervisor (SRS)/ Senior Program Manager (SPM) Consults QI regarding the need to notify OPWDD or IMU as not all 625 Events or Situations require the below contact. Notifies OPWDD or IMU for all deaths. Notifies OPWDD during normal business Notifies the OPWDD Incident Management Unit (IMU) during off business hours via ([email protected]) or hotline , depending on the severity of the incident If the incident is serious you must call the hotline #. Residential Director/Program Director Ensures the safety of the individual receiving services for all Events & Situations. Ensures necessary actions have been completed. Notifies QI Management Notifies Sub-Committee via QI Administrative Staff Immediately enters information from the 150 into IRMA within 48 hours 28

29 For all Reportable Abuse and Neglect Incidents: INVESTIGATION / REVIEW / MONITORING Investigation The Justice Center will delegate which Agency will conduct the investigation (JC Office for Investigation and Internal Affairs, People Inc.) for all Reportable Abuse/Neglect, Significant Incidents and Serious Notable Occurrences will be investigated by People Inc. QI Department. Minor Notable Occurrences will be investigated by the Program. The following Table delineates the process of Investigation Assignment: Type of Incident Investigated By Reviewed By Allegation of Abuse Reportable Abuse and Neglect Justice Center, OIIA, Agency Agency QI Investigator Assigned IRC and/or Justice Center Significant Incidents Agency QI and/or OIIA IRC Serious Notable Occurrences Minor Notable Occurrences Deaths Agency QI Program Management Staff Thorough Investigation Required Agency QI and/or Justice Center/OIIA IRC Sub-Committee M&M Committee, IRC, Justice Center/OIIA 625/150 Events Interventions by Program Sub-Committee Please Note: A written statement from the reporter will be completed if requested by investigator. The QI Department should be notified immediately upon discovery of any Physical or Sexual Abuse, Injury that requires hospitalization, Deaths, or any other egregious incident as determined by management. The QI Department AVP, Director, TL will assign incidents after they are received in QI and processed into IRMA. At that time, the person assigning will determine if the incident requires an investigator to go out within 24 hours to interview individuals, staff, and/or take pictures. For Injuries related to Serious Notable and Minor Occurrences, an electronic file will be utilized to store all pictures. Once pictures have been sent to QI they will be deleted from Digital camera. When an investigation and review by IRC is completed Guardian, Family Members or Correspondents who were notified of the incident will be contacted to inform them of the completion of the investigation and steps that are being taken to protect their relative/correspondent. If the notified party requests further information this will be documented and referred to the Quality Improvement Department. Program will enter date and contact information into Therap notification table For Minor Notable Occurrences being investigated by program staff; when it is discovered that a Serious Notable Occurrence or Reportable Incident may have occurred, during the investigation of the incident an allegation will be filed. QI will complete both investigations. 29

30 INVESTIGATION / REVIEW / MONITORING: Guidelines for ICF Investigations Each investigation related to persons living in an ICF is required to be completed within five (5) business days. This excludes Holidays and Weekends. The first day counted is the day QI is notified of the allegation. If an allegation is called in after 4pm on any given working day, day 1 should be considered the morning of the next working day. It is the responsibility of the program to ensure that all staff make every effort to cooperate in a timely mannergranting interviews, writing statement, etc. so the investigator is able to obtain all information needed to complete the report within the regulatory time-frame of 5 business days. It is the investigators responsibility to notify program management if staff are not cooperating with requests for information/interviews. Incidents involving a person who resides in a People Inc. ICF and that occur at another People Inc. program will be filed by that program and investigated within five (5) business days. 30

31 INVESTIGATION / REVIEW / MONITORING: Policy: The agency has an Incident Review Committee (IRC) to review and monitor reportable incidents and notable occurrences. Committee members will be appointed by the President and CEO of the Agency. This Committee is the Incident Review Committee (IRC). The functions of the IRC are: (see page 36 of Emergency Reg. effective 6/30/13 - (b)(1)(2)(3)(4)(5)). An Incident Review Committee shall review reportable incidents and notable occurrences to: (1) ascertain that reportable incidents and notable occurrences were reported, managed, investigated and documented consistent with the provisions of this Part and with agency policies and procedures and to make written recommendations to the appropriate staff and/or the chief executive officer to correct, improve or eliminate inconsistencies; (2) ascertain that necessary and appropriate corrective, preventive, remedial and/or disciplinary action has been taken to protect persons receiving services from further harm and to safeguard against the recurrence of similar reportable incidents and notable occurrences and to make written recommendations to the chief executive officer to correct, improve or eliminate inconsistencies; (3) ascertain if further investigation or if additional corrective, preventive, remedial and/or disciplinary action is necessary, and if so, to make appropriate written recommendations to the chief executive officer relative to the reportable incident or notable occurrence; (4) identify trends in reportable and notable occurrences (e.g., by type, person, site, employee involvement, time, date, circumstances, etc.), and to recommend appropriate corrective, preventive, remedial and/or disciplinary action to the chief executive officer to safeguard against such recurring situations or reportable incidents and notable occurrences; and (5) ascertain and ensure the adequacy of the agency's reporting and review practices, including the monitoring of the implementation of approved recommendations for corrective, preventive, and remedial action. Operation of the Incident Review Committee The IRC will meet on a monthly basis as scheduled by the Chairperson. Staff who have primary responsibility for investigating incidents may be invited to provide information, but will not be standing members of the Committee. Incidents will remain open and under review until Committee recommendations have been completed or scheduled for completion to the Committee s satisfaction. Incidents will remain open and under review until Committee Member s questions have been satisfactorily answered. In the event a preventative measure needs to be changed prior to the completion of the investigation or prior to the completed investigation being sent to the IRC, the director of the program will send the change electronically to all IRC members. 31

32 Plans for Prevention and Remediation for Substantiated Allegations of Abuse or Neglect 1) Within 10 days of the completion of the investigation, if the allegation of abuse or neglect has been substantiated, the agency shall develop and implement a plan of prevention and remediation to be taken to assure the continued health, safety, and welfare of individuals receiving services and to provide for the prevention of future acts of reportable incidents. 2) The plan shall include written endorsement by the CEO or designee. <Director or above> 3) The plan shall specify by title agency staff who are responsible for monitoring the implementation of each remedial action identified and for assessing the efficacy of the remedial action. 4) Such plan shall be entered into IRMA by the close of the fifth working day after the development of the plan (see subparagraph 624.5(e)(1)(iii) of the emergency regulation which was implemented 6/30/13). 32

33 SUB-COMMITTEE The Sub-Committees of the standing Incident Review Committee have been established for conducting reviews of: Minor Notable Occurrences 625/150 Events Internal Agency Incidents Medication Error Trends Behavior Incident Trends The Sub-Committees will always consist of at least one member of the standing IRC. Other members will include: Clinical Staff (ie: Behavior Specialist, RN, Other) QI Staff Senior Supervisors from Departments The Department Director Other membership as determined by IRC The Sub-Committee operations include: IRC Subcommittees will generally meet on a monthly basis, but at least every 60 days. IRC Subcommittees will review incident events for the same purposes as IRC Committee. IRC Subcommittees will keep incident/events open and under review until recommendations are complete or scheduled for completion to the Committee s satisfaction. IRC Subcommittees will keep incident events open and under review until all Committee Member s questions and concerns are addressed. In the event of an unresolved disagreement on a particular recommended course of action, the Chairperson of the Subcommittee will refer the issue to the IRC for resolution. Subcommittee Minutes will be subject to the review of IRC. Any questions and responses will be reflected in IRC Minutes. The Sub-Committee Members will: All committee members will continue to attend and review all investigation reports. An investigation must be started within 24 hours of the incident being reported. This means the individual is interviewed and a statement written. A picture is taken at this time if needed, by the SRS/SPM. Individuals will be asked if a picture can be taken. If individuals refuse or the SRS/SPM feels taking a picture would not be in the best interest of the person, a discussion with Director, AVP and QI will take place. A body check will be completed. This can be done at a natural time if this is deemed to be in the best interest of the individual. 33

34 SRS/SPM s are to get investigations completed in 3 weeks. All investigation reports must include the agency number. Financial investigations must be completed in 4 weeks. These investigations cannot be completed by the SRS/SPM of the site. The PD s should assign a SRS/SPM. o Any suspected theft or financial exploitation that is more than $15.00 and less than or equal to $ in value, that does not involve a debit, credit or benefit card, and that is an isolated occurrence, must be reported as a Minor Notable Occurrence. o Any suspected theft or financial exploitation that is less than or equal to $15.00 in value, that does not involve a debit, credit or benefit card, and that is an isolated occurrence, must be reported as an Internal Agency Incident and recorded on the Agency Incident Report (Appendix A). o If the Business Office had completed an audit this could be used with the SRS/SPM to report their findings as the investigation or as a part of it. For the ICF s all investigations need to be completed in (5) five days. Investigation report will be sent by the SRS s to their respective administrative support. When thorough investigations are completed the report should be sent out to all committee members (by program support staff) for review. This allows committee members to have time to read the investigation reports prior to the meeting. QI staff will complete their review of the report at this time as well. Any revision requests or questions from QI staff will be noted electronically on the report received and will then be sent back to program support staff electronically. These requests should then be forwarded to all committee members for review, again allowing members to read prior to the meeting. This also allows program support staff to reflect the information in the pre-minutes. Program should revise report answering any questions (do not delete questions) and highlight any information added. The final report should then be forwarded back to the program support staff (for inclusion in the pre-minutes) and QI Admins (to place a copy in the hard file). This should be done by the Wednesday prior to the Subcommittee meeting. Anything received after that, will be addressed at the next subcommittee meeting. Additionally, any other information that needs to go into the pre-minutes should be in by then as well. The pre-minutes are sent out the Monday before the Thursday Subcommittee meeting to all members of the group and QI. This will allow for review of all program responses prior to the Subcommittee meeting. The final minutes must be to QI by the last Monday of the month. Behavior trending and med errors need to be reviewed at the committee meetings. All incidents as defined and set forth anywhere herein are and are intended to be the same as set forth in applicable regulations. In the event of any disagreement, the applicable regulations will control. Any changes to applicable regulations are included herein automatically as an amendment hereto upon the effective date of said regulation. Nothing in this policy is intended or deemed to increase the coverage of applicable regulations or create obligations above or in addition to said regulations