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. The use of an emergency room by an individual, in place of the physician’s office, is not reportable.
  8. Suspicious Death 

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.

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 Direct Support Professional (DSP) agency to ensure that all information is correct.

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. 

How to Report and Work Through a Critical Incident:

Internal Incident Report Part A Session:

  1. Upon discovery of an incident, Service Coordinators are required to promptly initiate an investigation and make all necessary attempts to contact the involved parties. 
  2. When an incident is reported to a Service Coordinator, it is crucial to gather as much relevant information as possible within 24 hours. The Service Coordinator should prioritize collecting the following details:
    1. The date and time the incident occurred, the location, who was present, and any pertinent information regarding the incident. 
    2. If a hospitalization occurred, it is important to obtain information such as the hospital name, reason for admission, admission and discharge dates. 
    3. The Service Coordinator should also gather the contact information of the person who reported the incident, whether it was a family member, participant or provider.
  3. It is mandatory for Service Coordinators to immediately reach out to Adult Protective Services (APS) for participants under 60 and to the Office of Aging and Adult Protection Services (OAPS) for participants over 60 in cases of suspected exploitation, neglect, or abuse. This outreach must occur prior to completing incident report part A in order to ensure appropriate intervention and support for the participant.
  4. To ensure compliance, the Service Coordinator is required to complete part A of the incident report session within the Function Portal within 24 hours of discovering the incident.
    1. If the Service Coordinator is unable to gather all relevant information before the 24-hour deadline, they should still complete part A of the incident report and adjust the information for part B.
  5. A member of the Critical Incident (CI) Team will review the incident session prior to submitting the report to the Enterprise Incident Management (EIM) system within HCSIS.
  6. The CI team member will then create a task for the Service Coordinator, including the due date for the Change Event visit, the deadline for part B of the incident report, and any other pertinent information depending on the case. 
  7. It is imperative that Service Coordinators do not delay investigation activities until the day that the incident is scheduled for closure. Ensuring the safety and wellbeing of participants is of the utmost importance, and timely and thorough follow-up is critical to achieving this objective.

Internal Incident Report Part B Sessions:

  1. Part B of the incident report is a vital component that must include all measures taken to secure the health and safety of the participant, as well as actions taken to prevent or mitigate the recurrence of the critical incident. Furthermore, any changes made to the Person Centered Service Plan as a result of the incident should be thoroughly documented.
  2. To ensure comprehensive reporting, it is essential for Service Coordinators to obtain as much information as possible, which should include reaching out to the hospital or primary care physician’s office for discharge instructions. This is particularly crucial if the participant is unable to provide information related to their incident.
  3. Compliance with reporting requirements is essential, and the Incident Report Part B session must be completed within 20 days of discovering the incident. The Change Event visit must take place within 14 days of discovery, as specified within the task assigned by the CI team member. Adhering to these deadlines is crucial to ensure the proper management of critical incidents and the safety and wellbeing of participants.
  4. UTL: If the participant becomes Unable to Locate during the incident investigation, the following steps are required prior to part B completion:
  1. 3 unsuccessful outreaches to the all numbers on file for the participant including emergency contacts and PAS agency. 
  2. Reach out to all providers currently authorized to service the participant.
  3. Reach out to the PCP, Hospital, or Facility,
  4. Conduct a pop up visit and wellness check. 
  5. Additional steps may be required by the MCO which will be noted on the task from the CI team member.
  1. Extensions: In the event that a Service Coordinator encounters difficulties in obtaining all necessary information and anticipates that closure of the incident may not be possible within the allotted 20-day time frame, it is imperative that they promptly inform the CI team member. The CI team member will then initiate a request for an extension via the Enterprise Incident Management (EIM) system.
    1. Examples of situations that may warrant an extension include extended hospitalization, investigations by Adult Protective Services (APS) or the police, housing concerns, and difficulty locating the participant. It is critical that the Service Coordinator remains proactive in communicating any challenges they encounter during the incident reporting process to ensure that all necessary steps are taken to address the issue and ensure the safety and wellbeing of the participant. 
  2. Rehab: Service Coordinators are authorized to complete the incident report part B in the event that the participant is discharged to a rehabilitation facility. The following information must be obtained:
    1. The date of transition, the name of facility, and location of the facility. 
  3. Death: In cases where a death is deemed suspicious, it is imperative that Service Coordinators conduct a thorough investigation and confirm all pertinent information prior to finalizing part B of the incident report. Key information that must be gathered and verified includes:
    1. Contacting the Coroner and requesting toxicology testing
    2. Confirming whether the death resulted from choking or a fall
    3. Verifying whether Personal Assistance Services (PAS) hours were in place and how many
    4. Confirming whether a Home Health Aide (HHA) was present at the time of the incident
    5. Determining whether a significant health condition may have contributed to the death
    6. Verifying whether the participant had a terminal illness and, if so, whether hospice or palliative care was in place
    7. Determining whether a Do Not Resuscitate (DNR) was in effect or whether CPR was performed
    8. Confirming whether the participant was released directly to a funeral home.
  4. APS/OAPS: In cases where APS or OAPS is involved, it is imperative that the Service Coordinator keep in contact with the assigned investigator during the entirety of the investigation as well as providing updates to the CI team members to ensure that weekly follow-up is being provided into the EIM system.

Change Event Visit Refusal:

  1. In the event that a participant is refusing a change event visit, the Service Coordinator must ensure that the refusal process has been completed and accurately documented. 
  2. The Service Coordinator is also responsible to ensure that there is a preventative action plan put in place and added to the incident report part B, to prevent recurrence of the incident. 

Admission Tasks:

  1. Daily, PA Health and Wellness forwards reports containing details on participant hospitalizations. These reports are received by the Critical Incidents (CI) team, which assumes responsibility for generating tasks that the Service Coordinator will act upon.
  2. The Service Coordinator is accountable for attempting to reach out to the participant and/or their family members to obtain the necessary information related to the task. If the participant is unreachable within the 24 hour compliance time frame, the Service Coordinator must still complete the Incident Report Part A using the details provided within the task from the CIS.
  3. The Service Coordinator will then take on the responsibility of managing the above process “How to report and work through a critical incident”.

Direct Service Provider (DSP)/ Personal Assistance Services Provider (PAS) Reports:

  1. It is the responsibility of DSP agencies to report any critical incidents discovered within the EIM system. Effective from August 6th, 2022, DSP agencies are only authorized to initiate the incident first section. Once this section is completed, EIM will automatically link the report to the appropriate SCE agency who will then take charge of investigating and concluding the incident final section.
  2. Internally, when the Critical Incident Supervisor receives an incident report from a DSP agency, they will create a task for the Service Coordinator providing instructions on the requirement for the incident report part B and Change event Visit. 
  3. The Service Coordinator will then take on the responsibility of managing the above process “How to report and work through a critical incident”.

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. The Service Coordinator will then take on the responsibility of managing the above process “How to report and work through a critical incident”.

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. 

Root Cause Analysis and Risk Mitigation

  1. Root Cause Analysis (RCA): is a systematic process for identifying the underlying causes of problems or events and devising an effective approach for addressing them. It involves going beyond just putting out fires to prevent recurring problems and enhance problem-solving capabilities.
  2. Purpose: The purpose of RCA is to conduct a thorough review and assessment of the reasons behind the recurrence of critical events, and to identify areas for improvement in the Care Plan. By doing so, we can reduce the likelihood of event recurrence and improve outcomes for our participants. RCA is mandatory when a participant has experienced four or more critical events within a 12-month period.
  1. Goal: The goal of RCA is to gather data, review each critical incident event, and analyze the information to identify a common denominator or cause. We then evaluate the causes and explore corrective actions to prevent reoccurrence. This may involve consulting with the MD to make changes to the care plan, providing additional services that may benefit the participant, reviewing medication management, behavioral health, and making changes to PAS agencies regarding service interruptions.
  2. Plan: An RCA plan should be developed, implemented, and monitored. It is important to note that when conducting an RCA, the Service Coordinator should not call the participant and inquire about their barriers. Rather, it is an investigative process that requires collaboration between the Service Coordinator, the participant, the PCP, and the Nurse to identify the root causes and barriers.
  3. Internal Process: A member of the Critical Incident Team will receive an email from the Incident Team at PHW with the RCA request. The CI team member will open a task in Function Portal and assign it to the Service Coordinator, with a two-week due date. The Service Coordinator will be responsible for reviewing the incidents associated with the RCA and developing and implementing a preventative plan, which will be documented in Function Portal under the “Root Cause Analysis” session.
    1. Once the Service Coordinator has completed the RCA, it is the Supervisor’s responsibility to review and ensure that it has been completed correctly. The CI team member will then do a final review of the RCA and mitigation efforts to ensure quality before sending it to the Incident Reviewer at PHW to close the case. It is important to note that if the CI member discovers mistakes or little to no mitigation efforts documented, they will reopen the task for the Service Coordinator to revise.
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