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Critical Incident Reporting

Categories of Critical Incidents

  • Unplanned Hospitalizations
  • ER Visit
  • Service Interruption
  • Abuse
  • Neglect
  • Provider and Staff Misconduct
  • Exploitation of the Participant
  • Serious Injury
  • Reportable Disease
  • Suspicious Death

How to Report Critical Incidents

Internal Incident Report Part A:
  1. When the Service Coordinator “SC” is informed of an incident, they must gather as much of the following information as possible at that time.
    • Where did the incident occur?
    • What time did the incident take place?
    • Details regarding the incident
    • Who was, or should have been, present at the time of the incident?
    • If a hospitalization occurred: Which hospital? What was the admission reason/diagnosis? Admission date? Discharge date?
    • Who is reporting the incident?
      • The Participant? Family? Caregiver? Provider? Obtain their contact information
  2. With the information gathered, the SC then has to complete Incident Report Part A
    • SC has to reach out to their Supervisor for Incident Report Part A each time
      • It will be sent to their email via Docusign

Incident Report Part A MUST be completed within 24 hours of discovering the incident

  1. The SC is required to document the session in Function Portal under “Incident Report” and upload the PDF of their Incident Report.
    • Note: Upload the report, NOT the certificate of the report
  2. The Critical Incident Supervisor “CIS” will receive the Incident Report through Docusign and will submit the official incident report into the Enterprise Incident Management “EIM” system within HCSIS.

CIS is required to complete the EIM within 24 hours of receiving the incident report from the SC.

Trigger Event Visits

If the participant has experienced an ER visit, Hospitalization, or any significant change in their health/condition, then a Trigger Event visit is required to follow up with the participant.

The visit is required to take place within 14 days of the date of discovery

  • SC must obtain all information about the incident in order to finish Incident Report Part B.
    • Request Discharge paperwork/instructions if applicable
Internal Incident Report Part B: 
  1.  After the visit has occurred or after all information has been obtained regarding the incident, the SC must complete Incident Report Part B
    • SC has to reach out to their Supervisor for Incident Report Part B
      • It will be sent to their email via Docusign

Note: It is very important to obtain all information pertaining to the incident for Incident report part B. If the client is not providing enough information, or cannot remember the circumstances of the incident, the SC or CIS should reach out to the doctor, hospital, facility, etc if necessary.

  • Part B must include actions taken to secure the health and safety of the Participant, Measures taken to prevent or mitigate recurrence of the critical incident, Changes made to the Person Centered Service Plan as a result of the incident. 
  • The SC is required to document the session in Function Portal under “Incident Report” and upload the PDF of their Incident Report.
    •  Note: Upload the report, NOT the certificate of the report

Incident Report Part B MUST be completed within 20 days of discovering the incident

  • If the SC anticipates that the Trigger Event visit and/or the incident cannot be closed within the 20 day time frame, the SC MUST inform the CIS who will then request an extension through EIM. 
    • Extension examples:
      1. Extended Hospitalization
      2. Ongoing APS/Police investigation
      3. Housing Concerns
      4. Ptp is Unable to Locate

If participants were admitted into a Rehab facility and/or are UTL, SC MUST continue to attempt contact with them during open incidents

  1. The CIS will review Incident Report part B to confirm all required information has been provided and the CIS will then close out the EIM.

Blank Space

Clinical Information required for Hospitalizations: 
  1. Participant Name:
  2. Name of the Hospital:
  3. Discharge Date
  4. Discharge Diagnoses
  5. Changes to Current Medications or New Medications
    • Dosage
    • Route
    • Frequency
  6. Were treatments or Medical Equipment initiated by the Hospital?
  7. Was the ptp discharged to a SNF?
    • How long/duration:
    • Facility Name:
    • Date and Discharge of Transfer:
  8. Follow-up scheduled with PCP or Specialist/Date:
  1. Is there need for Skilled Services (Nursing, PT/OT) in home?
  2. Were there any changes to PAS or was the Service Plan adjusted or changed in amount, frequency, or Duration of existing supports and services.
  3. Are the ptp’s needs being met?
    • Concerns for the ptp’s safety?
    • Is the ptp at risk?
    • What has been put in place in the Plan of Care to address the concern?
  4. Measures taken to prevent or mitigate recurrence of incident:
  5. Was the participant provided education/steps to prevent further incidents?
Admission Notifications:

Tasks that come from PA Health and Wellness “PHW” explaining that the participant has been hospitalized. All admission notifications received from PHW, go directly to the CIS. 

  1. The CIS is responsible for completing the incident report part A with the information obtained in the Admission Notification and submitting the EIM. 
    • Part A and EIM are required to be completed within 48 hours of receiving the admission notification.
  2. Once the EIM has been submitted, the CIS will then send a confirmation email to the SC and Supervsior “SCS” informing them of the following: 
    1. The admission task information 
    2. The need to schedule a Trigger assessment within 14 days 
    3. Clinical questions that require follow up from the SC
      • The SC is responsible for providing responses to the clinical questions in Incident Report Part B within 20 days of discovery date.

Unacceptable vs Acceptable reporting: 

Categories by Definition 
  1.  Hospitalizations: an unplanned admission to the hospital. Including progression of disease, exacerbation or acute phase of known condition, new condition, injury or onset or treatment of a psychiatric disorder (including SUD). Usually preceded by an Emergency Room visit. 
    • Please keep in mind that planned hospitalizations do not need to be reported. (example: scheduled surgery and rehab admissions)
  1. Emergency Room Visit: an unplanned or emergent visit to a hospital emergency room as a result of an injury, illness or psychiatric disorder (including SUD) with a subsequent admission
  1. Service Interruptions: any event that results in the participant’s inability to receive services that places his or her health, and or safety at risk. This includes involuntary termination by the provider agency and failure of the participant’s back-up plan. If these events occur, the provider agency must have a plan for temporary stabilization.
    • Please keep in mind that not all missed visits are to be considered critical incidents. They only meet the threshold if the backup plan fails and there has been some harm to the participant. The following examples show whether or not an incident is required for Service Interruption:
      1. If Mom’s Meals does not show up, but the participant’s daughter was able to come over and cook the participant’s meals, this would not be a critical incident because the backup plan deployed and the participant did not go without meals. 
      2. On the other hand, if Mom’s meals does not show up and nobody was able to come to the participant to make their meals. This would be a critical incident because the participant went without nourishment. 
      3. Lastly, if Mom’s meals does not show up, nobody was able to make meals for the participant, but the participant was able to make themselves a Lean Cuisine, this would NOT be a critical incident.
        • Even though the backup plan did not deploy, the participant had no harm come to the participant.
  1.  Abuse and Neglect: 
    1. Abuse: an act or omission that willfully deprives a participant of rights or human dignity, or which may cause or causes actual physical injury or emotional harm to a participant.
      • Examples of Abuse: Physical abusem Psychological abuse, Verbal abuse, Sexual harassment of a participant, Sexual contact between a staff member and a participant, using restraints on a participant, humiliating a participant, withholding meals from a participant. 
    2. Neglect: the failure to provide an individual the reasonable care that he or she requires, including but not limited to food, clothing, shelter, medical care, personal hygiene, and protection from harm. Seclusion, which is the involuntary confinement of an individual alone in a room or an area from which the individual is physically prevented from having contact with others or leaving, is a form of neglect.
      • Examples of Neglect to look out for: Dehydration, malnutrition (without illness-related cause), untreated bedsores, and poor personal hygiene unattended, untreated health problems, hazardous or unsafe living conditions/arrangements, an injury that has not been cared for properly, inappropriate administration of medication, fear, anxiety, agitation, anger, isolation, depression, and hesitation to talk openly. 
  1. Exploitation: an act of depriving, defrauding, or otherwise obtaining the personal property of a participant in an unjust or cruel manner, against one’s will, or without one’s consent or knowledge for the benefit of self or others.
  1. Provider and Staff Misconduct: Including deliberate, willful, unlawful, or dishonest activities.
  1. Death: any death that is unanticipated, not expected or suspicious in nature. 
A Critical Incident is NOT: 
  1. A complaint associated with the dissatisfaction of program operations, activities or services received, or not received, involving home and community-based services 
  2. A concern related to benefit denials or the grievance (appeal) of a denial of service.
  3. Program fraud, waste, or abuse 
    • These are still reportable to the Bureau of Program Integrity (BPI) and the MCOs fraud hotline. 
  4. Pre-scheduled hospitalizations, or hospitalizations for routine illnesses should not be reported as critical incidents. 
  5. A death due to natural causes should not be reported as a critical incident. 
  6. Other events where it is important to notify the Participant’s service coordinator, but do not meet the criteria of a critical incident. 

Mandated Reporter: Immediate Action 

  1. Mandated Reporter: Anyone who is part of an organization of people that uses public funds (including waiver funds) and is paid, in part, to provide care and support to adults in a licensed or unlicensed setting is a mandated reporter. 
    • A mandated reporter is responsible to contact protective services for anyone, including individuals not on the waiver.
  1. Take Immediate Action: For cases of suspected Abuse, Neglect, Exploitation, Abandonment, or suspicious death, any provider, employee, or service coordinator must take immediate action to assure the Participant’s health and safety by contacting emergency medical services or law enforcement as applicable. 
  1. Make a verbal report to APS or OAPS (for categories listed above): 
    • Adult Protective Services (APS; for ages 18 to 59) Hotline at 1-800-490-8505. This number will transfer you to the appropriate place who will take the report. For critical incidents that are not immediate emergencies, the standard law enforcement phone number in the area should be used. 
    • Older Adult Protective Services (OAPS: Ages 60 & over) 
    • Link to PA Protective Services website for more information on reporting to APS/OAPS: http://dhs.pa.gov/citizens/reportabuse/dhsadultprotectiveservices 

Risk Mitigation

Risk Mitigation: the identification, evaluation, and prioritization of risks followed by coordinated resources to minimize, monitor, and control the probability or impact of unfortunate events. Service Coordinators are required to coordinate ways to prevent a client’s health from declining in order to prevent unplanned transitions. 

Importance: Risk Mitigation is a requirement for the Accreditation that Amcord Care withholds called the National Committee for Quality Assurance “NCQA”: how we measure our quality of work to improve healthcare by assessing clients for risk. 

Process: Being able to flag a participant for being a potential risk, researching ways to mitigate the risk to prevent potential harm, and tracking the outcome of mitigation efforts. 

Reporting Process: 
  1. If an SC believes that a participant should be flagged as a risk mitigation, they are required to reach out to their supervisor to discuss and then inform the Critical Incident Supervisor
    • The CIS reviews all incident reports and may flag participants when necessary. The CIS will then reach out to the coordinator to discuss possible mitigation approaches. 
  2. At the end of the month the CIS will reach out to the coordinator ro verify if the mitigation efforts have been successful or not. 
Examples of Flags 
  • Suicide prevention: (Important) As soon as a participant mentions thoughts or actions regarding ending their own life, the SC must call 911 for a wellness check, contact APS, complete an incident report, and inform the VP, of Operations. 
  • Multiple hospitalizations: This is circumstantial but is also the most common flag. If you recognize that the participant has been repeatedly hospitalized, they should be flagged for Risk Mitigation. 
    • This will depend on why the participant has been hospitalized. (i.e. If they went to the hospital for a stomach ache and then a month later went in for a common cold. They will not necessarily be flagged. However, if they went to the hospital both times because they are having wound care needs, then that is a flag and a good mitigation may be that this participant would benefit from at home skilled nursing care) 
  • Frequent falls: Mitigation efforts could be coordination of DME equipment, Home Modifications, or Physical Therapy services. 
  • Service interruptions: If the participant has not been receiving services that they have in place and their back up plan does not deploy, they should be flagged as a risk mitigation and the SC must coordinate with either the current provider or a new provider to ensure the participant is receiving their needed services. 
  • Any Repeated Concern 
Example of a Mitigation 

Flag: During your MTC, The participant indicated that they feel their physical health status is deteriorating despite PAS and ADC services already provided. The participant states that after visits to the doctor the previous week, her diabetes is not as in control as the doctor would like it to be. The participant states that she is not capable of maintaining the required diet necessary for her diagnosis. 

● You flagged the participant for risk of diabetes worsening and the participant is telling you that they do not currently have the resources to prevent this from happening 

Mitigation: You as the SC discussed with the participant possible choices for home delivered meals suitable for her diet. She selected a provider for meals that would suit the nutritional requirements for diagnosis and to help ensure her health will not decline further. You then provided her with educational materials about diabetes management and diet requirements. 

● You coordinated meals for the participant to assist with her diabetes. You also provided education on diabetes to help prevent future decline in health or possible hospitalizations 

Outcome: You followed up with the participant and she stated that she is doing well with meal delivery without instances of diabetic issues. The participant has reported good reports from her Primary Care Physician. 

● The Service Coordinator is required to follow-up with the participant to determine the outcome, one month after you have flagged them for risk. Keep in mind: Not all mitigation efforts will be successful. Some participants may not always be receptive to the assistance you are trying to provide. It is ultimately the participant’s decision but it’s the job of the SC to ensure you are doing the best you can to help prevent future risks.

Root Cause Analysis

Definition of Root cause analysis (RCA): is a systematic process for identifying “root causes” of problems or events and an approach for responding to them. RCA is based on the basic idea that effective problem solving requires more than merely “putting out fires” for problems that develop but finding a way to prevent them

Purpose: The purpose of the root cause analysis is to do an in-depth review and assessment into the reason for recurrence of critical events and identify areas of improvement opportunity in the Care Plan, thus ultimately reducing event recurrence and bettering outcomes for our participants. The goal of the RCA is to collect data, review each critical incident event and evaluate the information to find a common denominator or cause for the event. Evaluate the
causes and see if there are corrective actions to mitigate re-occurrence such as, reviewing with the MD for changes in plan of care, added services (not always PAS hours) that would benefit the participant, medication management, behavioral health, change to PAS agency (regarding service interruptions). This plan should be developed, implemented, and monitored. Please keep in mind that when you are required to complete an RCA, you are not calling the participant and asking them what their barriers are. This is an investigative process that requires a review by the Service Coordinator who will determine the reasonings and barriers. If assistance is needed with mitigation efforts, you may reach out to your AVP, VP, Nurse, and the Critical Incident Team for assistance.

Procedure: 

  1. The Critical Incident Supervisor (“CIS”) and assigned Service Coordinator (“SC”) will receive an email from a representative of the Critical Incident Team at PHW. The CIS will open a task in Function Portal which will be assigned to the SC and SCS with a due date of two weeks.
  1. The CIS will then send the RCA DocuSign to the assigned SC and SCS.
  1. The SCS should then log into EIM and download each incident report within the last 12 months for review.

If SCS needs assistance with logging in send an email to: CIreports@pahealthandwellness.com

  1. The SC has one week to complete the RCA template.
  1. Once the template has been completed by the SC, the SCS will then have one week to review and edit if applicable.
  1. Once the template has been reviewed by the SCS, the CIS will then have one week to review and edit if applicable.
  1. If the CIS still notes that the information provided is not sufficient, the CIS will extend the task in Function Portal, documenting what information is still required.
  1. Once the CIS has reviewed the RCA and deemed it ready to be sent back to the Critical Incident Team, the CIS will upload the note to Function Portal and Envolve and send the information through email to the appropriate CI Investigator.
  1. The SC and SCS are NOT required to document the final RCA note in Envolve.
Next Incident Reports A&B
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