Critical Incidents and Incident Reports A&B

Critical Incidents and Incident Reports A&B


Reportable Incident Categories:

  1. Protective Services Allegations (Abuse/Neglect/Exploitation)
  2. Provider and Staff Misconduct
  3. Service Interruptions
  4. Reportable Disease (if not reported within a hospitalization or ER visit)
  5. Serious Injury (if the participant sought treatment at ER/Hospital, use ER/Hospital as the primary category and serious injury as secondary category)
  6. Unplanned Hospitalization
  7. Emergency Room Visit: as of 6/1/2022 ER visits are only reportable for situations that are clearly emergencies, such as a serious injury, life-threatening medical conditions, medication errors, as well as those when an individual is directed to an emergency room in lieu of a visit to the PCP or as the result of a visit to the PCP.
  8. Suspicious Death 

Phase 1- Case Discovery:

  1. Identification and Reporting of the Critical Incident Event.
  2. Ensure health, safety, and welfare of the participant within 24 hours of event discovery.
  3. Collaborate with the DSP agency to ensure that all information is correct if events have been reported.

Phase 2- Case Investigation:

  1. Investigation and Evaluation of the Event, Developing Plan to support the participant and prevent the recurrence.
  2. Follow up MUST occur ongoing once the service coordinator is aware of the Critical Incident Event:
    1. Contact and follow up with the Acute Care Hospital to learn more about the ER/ Hospital visit.
    2. Contact the DSP agency to learn more about the event and address any allegations that are made against an employee of the agency and any event that caused injury to the participant. 
    3. Ensure that a Change Event visit is completed with the participant within 14 days of the event discovery. 
    4. Communicate with the PCP to help provide education to support the participant. 
    5. Consider additional resources available for risk mitigation efforts such as PHW LTSS CM team, community resources, volunteer resources, etc to support the participants needs and reduce recurrence of efforts. 
    6. Establish and maintain contact with the discharge planner in order to anticipate participant service/support needs upon discharge. 

Categories by Definition:

  1. Abuse: an act or omission that willfully deprives a participant of rights or human dignity, which may cause or causes actual physical injury or emotional harm to a participant. Examples include, Psychological abuse, Verbal abuse, Sexual harassment, Sexual contact between a staff member and a participant, using restraints on a participant, humiliating a participant, withholding meals from a participant. 
  1. 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. Service Interruptions: any event that results in the participant’s inability to receive services that places their heath, 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. (It is not considered a valid reportable service interruption if the back-up plan was utilized and did not fail). 
  1. Reportable Disease: (if not reported within a hospitalization or ER visit)
  1. Serious Injury: (if the participant sought treatment at ER/Hospital, use ER/Hospital as the primary category and serious injury as secondary category)
  1. Unplanned Hospitalization: Unplanned 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. 
  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. The use of an emergency room by an individual, in place of the physician’s office, is not reportable.
  1. Suspicious 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

  1. 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.

How to Report and Work Through a Critical Incident:

Incident Report Session Part A:

  1. When a Service Coordinator is informed of an incident, they must gather as much information as possible at that time and report within 24 hours. Information such as:
  • Where did the incident occur?
  • What time did the incident take place?
  • Details regarding the incident
  • If a hospitalization occurred: Which hospital? What was the reason? Admission date? Discharge date?
  • Who reported the incident?: Family, Participant, or Provider? Obtain their contact information. 
  1. The SC is required to complete the incident report part A session within Function Portal. This MUST be completed within 24 hours of discovering the incident.
  2. The Critical Incident Supervisor will review the incident session prior to submitting the report to the Enterprise Incident Management “EIM” system within HCSIS.
  3. The CIS will then create a task for the SC which will include the date that the Change Event visit is due, when the incident report part B is needed, and any other additional information that may be required. 
  4. Please keep in mind that if you are unable to obtain any information for report part A except for a date, or even a roundabout date, still report the incident ASAP. The rest of the information can be gathered and adjusted for part B. 

Incident Report Session Part B:

  1. Compliance: The incident Report Part B session is required to be completed within 20 days of discovering the incident, and the Change Event visit is required to take place 14 days after discovery. The due dates will be shown within the task opened by the CIS.
    1. Part B should be completed after the Change Event visit has occurred or after all information has been obtained regarding the incident. 
  2. Part B requirements: must include all 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.
    1. It is crucial that the SC obtain as much information as possible for Incident report part B which includes reaching out to the Hospital or PCP office for discharge instructions. This is a critical step especially if the participant is unable to provide information related to their incident. 
  3. UTL: If the participant becomes Unable to Locate during the incident investigation, the following steps are required:
    1. Follow the current required UTL process, 
    2. Reach out to the PCP, Hospital, or Facility,
    3. Conduct a pop up visit and wellness check. 
    4. Additional steps may be required by the MCO which will be noted on the task from the CIS. 
  4. Extensions: If the SC anticipates that the incident cannot be closed within the 20 day time frame, the SC should inform the Critical Incident Supervisor who will then request an extension through EIM.
    1. Extension examples: Extended hospitalization, APS/Police investigations, Housing Concerns, Unable to Locate.
  5. Rehab: if the participant is discharged to the rehab facility, the SC is able to complete the incident report part B as long as details are provided such as date of transition, rehab name and location. 

*Review Incident Session Part A & B Hospitalization example.

Note: SC are required to start the investigation and attempt all outreaches as soon as discovery of the incident is made. Do not wait until the day the incident is set for closure to follow up on the participants safety and wellbeing!!!

Admission Tasks:

  1. Reports come daily from PA Health and Wellness providing information regarding participant hospitalizations. The Critical Incident Supervisor is responsible for opening tasks for SC follow up.
  2. The SC is responsible for attempting outreach to the participant and or/ family in order to obtain information related to the task. If the participant is unable to be reached, the SC is still required to complete the Incident Report Part A with the information that has been provided from the CIS within the task. 
  3. The above steps should then be followed under “how to report a critical incident”.

PAS Agency Reports:

  1. DSP agencies are responsible for reporting critical incidents within the EIM system if they are the first to discover the incident.
  2. As of 8/6/2022, DSP agencies may ONLY initiate the incident first section. Once this happens, EIM will automatically link the report to the correct SCE agency who will then be responsible for the investigation and completion of the incident final section.
  3. Internal Process: When an incident is received from the DSP agency, the Critical Incident Supervisor will open a task for the SC which will provide directions for the need of the incident report part B and Change event Visit. The SC will then be responsible for the above process for incident investigation. 

Older Adult Protective Services Cases “OAPS or APS”:

  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.
    1. A mandated reporter is responsible to contact protective services for anyone, including individuals not on the waiver. Service Coordinators ARE Mandated Reporters.
  2. 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.
  3. Make a verbal report to APS or OAPS (for categories listed above):
    1. 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. 
    2. Older Adult Protective Services (OAPS: Ages 60 & over). All reports for Older Adult Abuse, etc. should be reported to the local AAA for that member, not the APS hotline above. 
    3. Link to PA Protective Services website for more information on reporting to APS/OAPS:
  4. Complete Incident report part A session. 
  5. The Critical Incident Team at PHW will be involved with these cases and require status updates weekly and meetings if needed. The Critical Incident Supervisor will monitor all communication from the SC and PHW through emails and tasks to ensure status updates are completed. 

Clinical Information required for Hospitalizations: 

  1. Participant Name: 
  2. Name of the Hospital: 
  3. Admission/Discharge Date: 
  4. Discharge Diagnosis: (Please do not list a symptom & it may be different from the initial diagnosis) 
  5. Changes to Current Medications or New Medications: Dosage and Route (how the medication is taken).
  6. Were treatments or Medical Equipment initiated by the hospital? 
  7. Was the participant discharged to a SNF?
    1. How Long/Duration: 
    2. Facility Name, Address & Phone
    3. Date and Discharge of Transfer: 
  8. Follow-up scheduled with PCP or Specialist/Date: 
  9. Is there a need for Skilled Services (Nursing, PT/OT) In home? 
  10. Were there any changes to PAS or Service Plan adjusted or changed in Amount, Frequency or Duration of existing supports and services? 
  11. Date of completed/scheduled Change Event.
  12. Date that services resumed for the member upon discharge from the hospital.
  13. Are the Participant’s needs being met?
    1. Concerns for Participants Safety? 
    2. Is the Participant at Risk? 
    3. If there is a concern, please indicate the Plan of Care that has been put in place: 
  14. Measures taken to prevent or mitigate recurrence of incident: 
  15. Was the Participant provided education/steps to prevent further incidents.
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