incident reporting...mdhhs/pihp contract attachment p7.7.1.1 reporting requirements suicide for any...
TRANSCRIPT
Incident ReportingNorthCare Network
2019
Learning Objectives
After completing this training it is expected that you will have a full understanding of:
Contract language
What is a sentinel event
What is a critical incident
What is a risk event
What is an immediately reportable event
Expectations of CMHSP
Expectations of PIHP
ELMER how to
Examples
Resources
Sentinel Event - MDHHS/PIHP Contract (pg. 12)
Sentinel Event: Is an “unexpected occurrence” involving death (not due to
the natural course of a health condition) or serious physical or
psychological injury or risk thereof.
Serious injury specifically includes permanent loss of limb or function.
The phrase “or risk thereof” includes:
any process variation for which recurrence would carry a significant chance of a
serious adverse outcome. (JCAHO, 1998)
Any injury or death that occurs from the use of any behavior intervention is
considered a sentinel event.
Sentinel Events (continued)- MDHHS/PIHP Contract Attachment P7.9.1
QAPIP
The QAPIP describes, and the PIHP implements or delegates, the process of the review and follow-up of sentinel events and other critical incidents and events that put people at risk of harm.
A. At a minimum, sentinel events as defined in the department’s contract must be reviewed and acted upon as appropriate. The PIHP or its delegate has three business days after a critical incident occurred to determine if it is a sentinel event. If the critical incident is classified as a sentinel event, the PIHP or its delegate has two subsequent business days to commence a root cause analyses of the event.
B. Persons involved in the review of sentinel events must have the appropriate credentials to review the scope of care.
C. All unexpected* deaths of Medicaid beneficiaries, who at the time of their deaths were receiving specialty supports and services, must be reviewed and must include:
Screens of individual deaths with standard information (e.g., coroner’s report, death certificate)
Involvement of medical personnel in the mortality reviews
Documentation of the mortality review process, findings, and recommendations
Use of mortality information to address quality of care
Aggregation of mortality data over time to identify possible trends.
Unexpected Deaths - MDHHS/PIHP Contract Attachment
P7.9.1 QAPIP
“Unexpected deaths” include those that resulted from suicide, homicide,
an undiagnosed condition, were accidental, or were suspicious for possible
abuse or neglect.
ELMER Code: D01
Root Cause Analysis (RCA)- MDHHS/PIHP Contract Section
6.1Critical Incidents(p.52)
Based on the outcome of the analysis or investigation, the provider must
ensure that a plan of action is developed and implemented to prevent
further occurrence of the sentinel event.
The plan must identify who is responsible for implementing the plan,
And how implementation will be monitored.
Alternatively, the provider may prepare a rationale for not pursuing a
preventive plan.
The PIHP is responsible for oversight of the above processes.
The RCA can be completed in the ELMER reporting system, if not- please scan
and attach to the associated Incident Report.
RCA - Discoverable
Per Legal opinion, the Incident Report and RCA are discoverable if shared outside the designated Quality Improvement Committee.
Put enough information in the IR/RCA to know what happened; but not too much. (make it a summary)
Don’t ID staff by full name
Don’t include analysis or investigatory documentation
Do report the incident and complete an RCA, as indicated
Do identify internal/external factors and summarize recommendations to prevent future reoccurrence
Do store additional notes in a secure location outside of ELMER
Do follow up if the problem persists
Do indicate who participated in RCA
RCA- Considerations- CMHCM (CMH for Central Michigan)
Method/Procedure:
Was the recipient’s Person-Centered Plan (PCP) adequate?
Was the recipient’s PCP complete?
Did written policies, protocols, and procedures exist?
Were staff aware of risks and thinking about how to prevent them?
Communication:
How was information provided to staff?
Were there barriers to communication?
Were staff aware of the consumer’s PCP?
Were staff aware of the organization’s procedures, policies and protocols?
Was information/instructions missing?
Was information/instructions confusing or contradictory?
Staff Related:
What were staffing levels at the time of the incident?
What training had staff received? Were staff trained on IPOS? On Behavioral Plan?
Did staff have skills required to implement procedures?
Environment:
Was the environment noisy?
How much space was available to consumers and staff?
Was lighting adequate?
Were any physical hazards present?
Had Emergency Response Procedures been developed?
Equipment/Materials:
Was equipment available?
Was equipment used properly?
Was equipment in good condition?
Were surfaces safe?
Critical Incidents – MDHHS/PIHP Contract Attachment P7.7.1.1
Reporting Requirements
Critical Incidents must identify if the incident is sentinel.
PIHP’s report CI within 60 days for individuals actively* receiving services
Suicide**
Non-suicide death
Emergency medical Tx due to injury or medication error
Hospitalization due to injury of medication error
Arrest of consumer
** different timeframe
Actively Receiving Services - MDHHS PIHP Incident
Warehouse Documentation Guidance
A consumer is considered to be actively receiving services when any of the following occur:
A face-to-face intake has occurred and the individual was deemed eligible for ongoing service, or
The CMHSP/PIHP has authorized the individual for ongoing service, either through a face to face assessment or a telephone screening, or
The individual has received a non-crisis, non-screening encounter.
The period during which the consumer is considered to be actively receiving services shall take place between the following begin date and end date, inclusively:
Beginning Date: Actively receiving services begins when the decision is made to start providing ongoing non-emergent services. Specifically, the beginning date shall be the first date that any of the 3 conditions referenced above occurs.
End Date: when the consumer is formally discharged from services. The date the discharge takes effect shall be the end date. This should also be the date that is supplied to the consumer when the consumer is notified that services are terminated.
Note: the end date does not happen until the consumer is ‘formally discharged,” so be sure to complete the paperwork (e.g. dc notice).
Suicide – MDHHS/PIHP Contract Attachment P7.7.1.1 Reporting Requirements
Suicide for any individual actively receiving services at the time of death,
and any who have received emergency services within 30 days prior to
death.
Once it has been determined whether or not a death was suicide, the
suicide must be reported within 30 days after the end of the month in which
the death was determined.
If 90 calendar days have elapsed without a determination of cause of
death, the PIHP must submit a “best judgment” determination of whether
the death was a suicide. In this event the time frame described in “a”
above shall be followed, with the submission due within 30 days after the
end of the month in which this “best judgment” determination occurred.
Non-Suicide Death
Non-suicide death for individuals who were actively receiving services and
were living in a Specialized Residential facility (per Administrative Rule
R330.1801-09) or in a Child-Caring institution;
or were receiving community living supports, supports coordination,
targeted case management, ACT, Home-based, Wraparound, Habilitation
Supports Waiver, SED waiver or Children’s Waiver services.
If reporting is delayed because the PIHP is determining whether the death
was due to suicide, the submission is due within 30 days after the end of the
month in which the PIHP determined the death was not due to suicide.
Emergency Medical Tx due to Injury/
Med Error
Emergency Medical treatment due to Injury or Medication Error for people
who at the time of the event were actively receiving services and were
living in a Specialized Residential facility (per Administrative Rule R330.1801-
09) or in a Child-Caring institution;
or were receiving either Habilitation Supports Waiver services, SED Waiver
services or Children’s Waiver services.
Hospitalization due to Injury/Med Error
Hospitalization due to Injury or Medication Error for individuals who were
living in a Specialized Residential facility (per Administrative Rule R330.1801-
09) or in a Child-Caring institution;
or receiving Habilitation Supports Waiver services, SED Waiver services, or
Children’s Waiver services.
Arrest of Consumer
Arrest of Consumer for individuals who was living in a Specialized Residential
facility (per Administrative Rule R330.1801-09) or in a Child-Caring institution
at the time of the arrest;
or receiving Habilitation Supports Waiver services, SED Waiver services, or
Children’s Waiver services at the time of the arrest.
Critical Incident Reporting System –MDHHS/PIHP Contract Attachment P7.9.1 QAPIP
Reporting system required since 10.1.11
Five specific reportable events (recap):
Suicide
Non-Suicide Death
Emergency Medical Tx due to injury or medication error
Hospitalization due to injury or medication error
Arrest of consumer
Remember: unexpected deaths require review of 5 identified points
Screens of individual deaths with standard information (e.g., coroner’s report, death certificate)
Involvement of medical personnel in the mortality reviews
Documentation of the mortality review process, findings, and recommendations
Use of mortality information to address quality of care
Aggregation of mortality data over time to identify possible trends.
CI Reporting System
Implemented to help MDHHS gain a consumer-specific view of population
events, in part to meet CMS (Centers for Medicare and Medicaid)
reporting requirements.
Has helpful information; including FAQ’s.
https://mipihpwarehouse.org/MVC/Documentation
Service Suicide Death EMT Hospital Arrest
CLS ● ●
Supports Coord ● ●
Case Management ● ●
ACT ● ●
Homebased ● ●
Wraparound ● ●
Hab Waiver ● ● ● ● ●
SED Waiver ● ● ● ● ●
Child Waiver ● ● ● ● ●
Any other Service ●
Living Situation
Specialized Residential ● ● ● ● ●
CCI ● ● ● ● ●
Risk Events Management - MDHHS/PIHP Contract
Attachment P7.9.1 QAPIP
The QAPIP has a process for analyzing additional critical incidents that put
individuals (in the same population categories as the critical incidents
above) at risk of harm. This analysis should be used to determine what
action needs to be taken to remediate the problem or situation and to
prevent the occurrence of additional events and incidents. MDHHS will
request documentation of this process when performing site visits.
These events minimally include:
Actions taken by individuals who receive services that cause harm to themselves
Actions taken by individuals who receive services that cause harm to others
Two or more unscheduled admissions to a medical hospital (not due to planned
surgery or the natural course of a chronic illness, such as when an individual has
a terminal illness) within a 12-month period
Immediately Reportable Events The PIHP shall immediately notify MDHHS of the following events:
Any death that occurs as a result of suspected staff member action or inaction, or any death that is the subject of a recipient rights, licensing, or police investigation. This report shall be submitted electronically within 48 hours of either the death, or the PIHP’s receipt of notification… and include the following information:
a. Name of beneficiary
b. Beneficiary ID number (Medicaid, MiChild)
c. Consumer (CONID) if there is no beneficiary ID number
d. Date, time and place (if a licensed foster care facility, include the license #)
e. Preliminary cause of death
f. Contact person’s name and E-mail address
Relocation of a consumer’s placement due to licensing suspension or revocation. 5 business days to report this, and the following
An occurrence that requires the relocation of any PIHP or provider panel service site, governance, or administrative operation for more than 24 hours
The conviction of a PIHP or provider panel staff members for any offense related to the performance of their job duties or responsibilities which results in exclusion from participation in federal reimbursement.
If submitting
the IR-
NorthCare will
be notified
once the IR is
signed. If you
can’t
complete the
IR within 24
hours, please
call Diane or
Brittany.
When to Report to the following
Licensing
CPS/APS
Police
Office of Recipient Rights
Be sure to Document that you reported.
We are mandated to report, therefore you will want this documented.
Please be sure to document who reported (staff name/title) to whom name and
title if known) at what agency and the date you reported.
If you
see/hear it;
report it!
Licensing
The Bureau of Community and Health Systems (BCHS) accepts and processes complaints against various state licensed and federally certified facilities, centers, homes, agencies, and programs.
To make a complaint against a licensed home; you can fill out an online form: https://www.michigan.gov/lara/0,4601,7-154-89334_63294_27723_27777_72411---,00.html
Multiple resources are available on LARA
Licensing
An APS/CPS (Adult Protective Service/Child Protective Service) or law enforcement referral does not automatically get generated by a licensing complaint.
Once the consultant receives the complaint then the consultant will contact the complainant to see if the complainant has already contacted APS/CPS and law enforcement.
It is determined at that time who will file the formal complaints.
It is usually good for the complainant to file the APS/CPS and law enforcement complaints because they are the person with the first hand knowledge of the situation.
Complaints Licensing files are very generic and are missing much of the important information that is needed for that APS/CPS and law enforcement referral.
If the complainant is not comfortable making an APS/CPS and law enforcement complaint then the licensing consultant will file a complaint for both.
This may take some communication between the parties to know who filed the complaint.
*Information from Andrew Silver at MDHHS
CPS
Michigan Child Protection
Law requires certain
professionals to report their
suspicions of child abuse or
neglect to Children's
Protective Services (CPS) at
the Department of Human
Services (DHS).
Mandated Reporters Include:
PhysiciansLicensed emergency medical care
providers.
Licensed master social workers. School counselors.
Dentists. Audiologists.
Licensed bachelor's social workers. Teachers.
Physician's assistants. Psychologists.
Registered social service technicians. Law enforcement officers.
Registered dental hygienists. Marriage and family therapists.
Social service technicians. Members of the clergy.
Medical examiners. Licensed professional counselors.
Persons employed in a professional
capacity in any office of the Friend of the
Court.
Regulated child care providers.
Nurses. Social workers.
School administrators.
Employees of an organization or entity
that, as a result of federal funding
statutes, regulations, or contracts, would
be prohibited from reporting in the
absence of a state mandate or court
order (example: domestic violence
provider).
APS
The Social Welfare Act, Act 280 of 1939, Section 400.11a Reporting abuse, neglect, or exploitation of adult; oral report; contents of written report; reporting criminal activity; construction of section states:
➢ A person who is employed, licensed, registered, or certified to provide health care, educational, social welfare, mental health, or other human services;
➢ an employee of an agency licensed to provide health care, educational, social welfare, mental health, or other human services;
➢ a law enforcement officer;
➢ or an employee of the office of the county medical examiner
who suspects or has reasonable cause to believe that an adult has been abused, neglected, or exploited shall make immediately, by telephone or otherwise, an oral report to the county department of social services of the county in which the abuse, neglect, or exploitation is suspected of having or believed to have occurred.
After making the oral report, the reporting person may file a written report with the county department.
A person described in this subsection who is also required to make a report pursuant to section 21771 of the public health code, Act No. 368 of the Public Acts of 1978, as amended, being section 333.21771 of the Michigan Compiled Laws and who makes that report is not required to make a duplicate report to the county department of social services under this section.
Police
If there is risk of imminent harm, contact police.
Per 330.1723 of the MHC: report in the following situations:
Assault (other than patient-patient assault/battery)
Criminal Sexual Abuse
Homicide
Vulnerable Adult Abuse
Child Abuse
*Information from Andrew Silver at MDHHS
Mental Health Code Reporting Requirement -Section 330.1723
Suspected abuse of recipient or resident; report to law enforcement agency.
(1) A mental health professional, a person employed by or under contract to the department, a licensed facility, or a community mental health services program, or a person employed by a provider under contract to the department, a licensed facility, or a community mental health services program who has reasonable cause to suspect the criminal abuse of a recipient immediately shall make or cause to be made, by telephone or otherwise, an oral report of the suspected criminal abuse to the law enforcement agency for the county or city in which the criminal abuse is suspected to have occurred or to the state police.
(2) Within 72 hours after making the oral report, the reporting individual shall file a written report with the law enforcement agency to which the oral report was made, and with the chief administrator of the facility or agency responsible for the recipient.
(3) The written report required by subsection (2) shall contain the name of the recipient and a description of the criminal abuse and other information available to the reporting individual that might establish the cause of the criminal abuse and the manner in which it occurred. The report shall become a part of the recipient's clinical record. Before the report becomes part of the recipient's clinical record, the names of the reporting individual and the individual accused of committing the criminal abuse, if contained in the report, shall be deleted.
(4) The identity of an individual who makes a report under this section is confidential and is not subject to disclosure without the consent of that individual or by order or subpoena of a court of record. An individual acting in good faith who makes a report of criminal abuse against a recipient is immune from civil or criminal liability that might otherwise be incurred. The immunity from civil or criminal liability granted by this subsection extends only to acts done under this section and does not extend to a negligent act that causes personal injury or death.
(5) An individual who makes a report under this section in good faith shall not be dismissed or otherwise penalized by an employer or contractor for making the report.
(6) This section does not relieve an individual from the duty to report criminal abuse under other applicable law.
(7) The department, a community mental health services program, a licensed facility, and a service provider under contract with the department, community mental health services program, or licensed facility shall cooperate in the prosecution of appropriate criminal charges against those who have engaged in criminal abuse.
(8) Except as otherwise provided in subsection (5), this section does not preclude nor hinder the department, a licensed facility, a community mental health services program, or a service provider under contract to the department, a licensed facility, or a community mental health services program from investigating reported claims of criminal abuse of a recipient by its employees, and from taking appropriate disciplinary action against its employees based upon that investigation.
Mental Health Code Reporting Requirement - Section 330.1723 continued
(9) This section does not require a person to report suspected criminal abuse if either of the following applies:
(a) The individual has knowledge that the incident of suspected criminal abuse has been reported to the appropriate law enforcement agency as provided in this section.
(b) The suspected criminal abuse occurred more than 1 year before the date on which it first became known to an individual who would otherwise be required to make a report.
(10) This section does not require an individual required to report suspected criminal abuse under subsection (1) to disclose confidential information or a privileged communication except under 1 or both of the following circumstances:
(a) If the suspected criminal abuse is alleged to have been committed or caused by a mental health professional, an individual employed by or under contract to the department, a licensed facility, or a community mental health services program, or an individual employed by a service provider under contract to the department, a licensed facility, or a community mental health services program.
(b) If the suspected criminal abuse is alleged to have been committed in 1 of the following:
(i) A state facility or a licensed facility.
(ii) A county community mental health services program site.
(iii) The work site of an individual employed by or under contract to the department, a licensed facility, or a community mental health services program or a provider under contract to the department, a licensed facility, or a community mental health services program.
(iv) A place where a recipient is under the supervision of an individual employed by or under contract to the department, a licensed facility, a community mental health services program, or a provider under contract to the department, a licensed facility, or a community mental health services program.
Office of Recipient Rights
All IR’s are routed to CMHSP’s Recipient Rights officers.
Does a CMHSP RRO have jurisdiction for investigating incidents in the
following scenarios:
A consumer-to-consumer incident in a non-contracted residential facility
(general AFC) or program?
YES, if they are receiving CMH services
A consumer-to-consumer incident in a community setting with staff? Without
staff?
YES, if they are receiving CMH services
If a consumer returns from a family home (parent, sibling, etc.) with an
injury? What agency(ies)/Who should this be reported to?
ORR may be involved. Should be reported to APS or CPS as appropriate.
*Information from Andrew Silver, MDHHS
If you
see/hear it;
investigate it!
Expectations of CMHSP
Completion of IR’s in the ELMER system (can be scanned) with appropriate indication of type of IR (sentinel, critical, risk, CMH, immediate reportable).
Timely review and indication if event type by CMH staff and RRO (SE within 3 days).
All IR’s must be marked “yes” or “no” for each type (sentinel, critical, etc.)
Accurate reporting to the appropriate agencies in the identified acceptable timeframe.
Doing due diligence to obtain death reports for consumers.
Completing RCA’s timely, with appropriate staff signature. Be sure to indicate what preventative measures will be put in place to prevent this from occurring again.
Reviewing data to identify trends, discussing concerns related to those trends, and implementing a process to address negative trends.
These are all elements to NorthCare site review; therefore data will need to be available.
Expectations of PIHP
Monitor incident reporting for proper coding
Conduct summary reviews as requested
Identify regional trend data periodically
Report “immediately reportable” events to the department
Provide training and technical assistance to staff as needed
ELMER
If you have difficulty with how to enter incidents into ELMER, the ELMER HELP
guide is useful.
Reporting and Coding in ELMER
Anyone can complete an incident report. If staff feel like something is an
incident- they should report it. (Do not need supervisory approval to
report.)
Each incident must have a code and be marked yes or no for each
category
Sentinel, risk, critical, immediately reportable, CMH event.
These need to be marked timely. Remember a CMH has 3 days to determine if
an event is Sentinel.
Critical Incidents need to be reported within 60 days following the end of the
month.
Examples; Think about your response
An AFC consumer reports that a staff pushed him. Bruises are noticed on
arms.
To whom should you report (list all)?
How would reporting change if the consumer lived in a private home?
A consumer lives in a specialized residential facility, however has an event
happen when they are out of the home visiting their sister. The event is a fall
requiring emergency medical care. You are made aware by the sister who
calls you the next day.
Do you report? to whom?
A home has a fire. Six consumers live in the home. None are hurt, but all
have to spend the night elsewhere.
How many times do you report?
Is this immediately reportable?
How would this change if 1 consumer was hurt?
Example Answers
1. An AFC consumer reports that a staff pushed him. Bruises are noticed on arms.
a. To whom do you report? ORR, APS/CPS, police, licensing, guardian, HR
b. How would reporting change if the consumer lived in a private home? You wouldn’t contact licensing
2. A consumer lives in a specialized residential facility, however has an event happen when they are out of the home visiting their sister. The event is a fall requiring emergency medical care. You are made aware by the sister who calls you the next day.
a. Do you report? Yes, This would be a critical incident.
3. A home has a fire. Six consumers live in the home. None are hurt, but all have to spend the night elsewhere
a. How many times do you report? Report once as facility incident
b. Is this immediately reportable? Yes, immediately reportable due to relocation of service site for over 24 hours
c. How would this change if 1 consumer was hurt? If one or more consumers are harmed, in addition to the facility incident you would also report a CI or SE depending on severity of harm for each consumer harmed. * The harm is not immediately reportable (unless death caused by staff action/inaction).
OTHER- Behavioral Tx Review (BTC)and
Analysis
While BTC review isn’t completed in the incident reporting module- BTC
staff will need to be aware of incidents.
The QAPIP requires quarterly reviews and analyses of data from the
behavior treatment review committee where intrusive or restrictive
techniques have been approved for use with beneficiaries and where
physical management or 911 calls to law enforcement have been used in
an emergency behavioral crisis.
Only the techniques permitted by the Technical Requirement for Behavior
Treatment Plans and that have been approved during person-centered
planning by the beneficiary or his/her guardian, may be used with
beneficiaries.
Data shall include numbers of interventions and length of time the
interventions were used per person.
Resources
PIHP Incident Warehouse:
https://mipihpwarehouse.org/MVC/Documentation
FY20 MDHHS/PIHP Contract and Attachments
P7.9.1 QAPIP
P7.7.1.1 PIHP Reporting Requirements
ELMER Help Guide
www.cmhcm.org/userfiles/filemanager/137
NC Incident Reporting Policy
Social Welfare Act
MDHHS
LARA
Mental Health Code Sections 330.1700 and 330.1723
