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Division of Mental Health and Addiction
Critical Incident Reporting
Policy and Procedure
June 2019
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Agenda
• Purpose and objectives• Types of incident reports• Reporting Requirements• Quality Assurance• Wrap-up and Questions
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Purpose
Incidents will happen… Staff and Consumer safety
• How do you respond, report, resolve and remedy Federal and State Mandates
Objectives
Know how to complete incident reports Understand the changes for reporting
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Types of IncidentsResidential Settings Community Based/Client’s Home
Fire requiring a local fire department response
Injury
Any emergency rendering the residence temporarily or permanently uninhabitable
A suicide/suicide attempt by a resident
Any serious injury of a resident requiring professional medical attention
Death
Suspected or alleged exploitation, neglect or abuse
Homicide
A suicide/suicide attempt by a resident Medication Error
Incident involving the resident requiring a police response- Assault on staff/client
Suspected or alleged exploitation, neglect or abuse
Medication Error
Elopement
Seclusion and Restraint
Death
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Critical Incident ReportingRequirements
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Reporting Time Frames
• Residential Settingso Within 24 hours
• Outpatient/Community Setting/Client’s Homeo Within 72 hours of CMHC being notified
Resource: State Plan Amendment (SPA) and Article 7.5 Residential Living Facilities for Individuals with Psychiatric Disorders or Addictions
***Now Active***CIR Portal ChangeIdentify reason the incident was not reported within required timeframe
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Required InformationAbuse, Neglect and/or Exploitation Medication Errors
Names of those involved in the incident and relation to victim
How was the incident addressed
Was Adult Protective Service (APS) contacted Describe the preventative measures to decrease likelihood of incident reoccurring
Describe how the client will be kept safe during the investigation
Title/Credentials of staff completing incident report
If the accusation was against the staff, how was that handled
Describe reason the CIR was not submitted within required time frame (24 vs. 72 hours)
Describe the preventative measures to decrease the likelihood of incident reoccurring
When the doctor was contacted, what were the instructions to staff and/or client to address possible medical concerns or adverse drug responses
Describe reason the CIR was not submitted within required time frame (24 vs. 72 hours)
How was the incident resolved
Title/Credentials of staff completing incident report
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Critical Incident Reporting Compliance
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0%
20%
40%
60%
80%
100%
Qtr 1 Qtr 2 Qtr 3 Qtr 1 Qtr 2 Qtr 3 Qtr 4
48%
75%83%
60% 55%
74%58%
SFY 2019
CRITICAL INCIDENT REPORTING
SFY 2018
Reporting ComplianceProvider Goal: 86%
22%
58% 59%
0%
10%
20%
30%
40%
50%
60%
70%
SPY 1 SPY 2 SPY 3
3 YEAR REPORT2014-2017
SPY= State Plan Year
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Critical Incident Quality Assurance Processes
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Compliance Process: How will it work?
• BPHC: Begins September 1, 2019• AMHH: Begins October 1, 2019• Each CMHC will receive a report of their compliance scores for each quarter• Report will be provided 15 days from end of quarter
• Including any additional follow-up forms provided to the CMHC
BPHC Quarters AMHH Quarters1st June 1- August 30 1st October 1- December 312nd September 1-November 30 2nd January 1-March 313rd December 1-February 28 3rd April 1-June 304th March 1-May 31 4th July 1-September 30
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Resource: 405 IAC 1-1.4-4 Sanctions against providers; determination after investigation
Informal Adjustment (IA)
After first 90 day non-compliant CIR review:• Verbal or email guidance to the provider and the primary
contact or provider supervisor as deemed most appropriate by QA/QI staff.
• DMHA will provide data to show compliance issues including incident date and staff member that submitted CIR
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After second 90 day non-compliant CIR review• A “Formal Notice” is sent via email (with read receipt or
including a request to respond confirming receipt) to the CEO and identified primary contact of the provider
• DMHA will provide data to show compliance issues including incident date and staff member that submitted CIR
• The education letter will identify the next steps if a third 90 day non-compliance review occurs.
Educational Letter (EL)
NOTE: If after two quarters since EL, compliance falls below 86%, an Informal adjustment will be issued again
Resource: 405 IAC 1-1.4-4 Sanctions against providers; determination after investigation
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This occurs after the third 90 day non-compliant CIR review
DMHA Notice: A “Formal Notice” letter written on FSSA letterhead
requiring corrective action and an accompanying Corrective Action
Plan (CAP) are sent to the provider for response.
The CAP must include the following information: Responsible party Timeframe for completion A way for DMHA to verify the CAP has been completed Plan to prevent reoccurrence Be effective
Corrective Action Plan
NOTE: If after two quarters since CAP, compliance falls below 86%, an Educational Letter will be issued again
Resource: 405 IAC 1-1.4-4 Sanctions against providers; determination after investigation
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Additional Action Steps
• Mandatory re-trainings • Increase visits based on progress• Increase request for documentation• Staff member must be re-trained before providing service going
forward
Resource: 405 IAC 1-1.4-4 Sanctions against providers; determination after investigation
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• Decertification of specific staff members• Referral to FSSA Audit • Program Integrity
Graduated Sanctions
Resource: 405 IAC 1-1.4-4 Sanctions against providers; determination after investigation
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