Critical Incident Report User Guide Form 470-4698 - Iowa Medicaid ...

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Iowa Department of Human ServicesIMPA Incident Reporting FormIMPA Users Guide – Revised May, 2010INCIDENT REPORTINGThese incident reporting standards apply only to providers who have direct contact with members. The standards define“major” and “minor” incidents, and set procedures and prescribe the content of incident reports.MINOR INCIDENTS -- means an occurrence involving a member during service provision that is not a majorincident and that:1. Results in the application of basic first aid;2. Results in bruising;3. Results in seizure activity;4. Results in injury to self, to others, or to property; or5. Constitutes a prescription medication error.Reporting Procedure for Minor Incidents may be reported in any format designated by the provider. When a minorincident occurs or a staff member becomes aware of a minor incident, the staff member involved shall submit thecompleted incident report to the staff member’s supervisor within 72 hours of the incident. The completed report shallbe maintained in a centralized file with a notation in the member’s file.MAJOR INCIDENTS -- means an occurrence involving a member during service provision that:1. Results in a physical injury to or by the member that requires a physician’s treatment or admission toa hospital;2. Results in the death of any person;3. Requires emergency mental health treatment for the member;4. Requires the intervention of law enforcement;5. Requires a report of child abuse pursuant to Iowa Code section 232.69 or a report of dependent adultabuse pursuant to Iowa Code section 235B.3;6. Constitutes a prescription medication error or a pattern of medication errors that leads to theoutcome in numbered paragraph “1,” “2,” or “3”; or7. Involves a member’s location being unknown by provider staff who are assigned responsibility foroversight.Reporting Procedure for Major IncidentsWhen a major incident occurs or a staff member becomes aware of a major incident:1. The staff member involved shall notify the following persons of the incident by the end of the next calendarday after the incident:a. The staff member’s supervisor.b. The member or the member’s legal guardian. EXCEPTION: Notification to the member is required onlyif the incident took place outside of the provider’s service provision. Notification to the guardian, if any,is always required.c. The member’s case manager.2. By the end of the next calendar day after the incident, the staff member who observed or first became awareof the incident shall report as much information as is known about the incident. The provider will report to thedepartment’s bureau of long-term care either:a. By direct data entry into the Iowa Medicaid Provider Access System, orb. By faxing or mailing Form 470-4698, Critical Incident Report, according to the directions on the form.3. The following information shall be reported:a. The name of the member involved.b. The date and time the incident occurred.c. A description of the incident.Page 4
Iowa Department of Human ServicesIMPA Incident Reporting FormIMPA Users Guide – Revised May, 2010d. The names of all provider staff and others who were present at the time of the incident or whoresponded after becoming aware of the incident. The confidentiality of other members or non-memberswho were present must be maintained by the use of initials or other means.e. The action that the provider staff took to manage the incident.f. The resolution of or follow-up to the incident.` g. The date the report is made and the handwritten or electronic signature of the person making thereport.4. Submission of the initial report in IMPA will generate a workflow in ISIS for follow-up by the case manager.When complete information about the incident is not available at the time of the initial report, the providermust submit follow-up reports until the case manager is satisfied with the incident resolution and follow-up. Thecompleted report shall be maintained in a centralized file with a notation in the member’s file.5. Tracking and analysis. The provider shall track incident data and analyze trends to assess the health and safetyof members served and determine if changes need to be made for service implementation or if staff training isneeded to reduce the number or severity of incidents.FORM 470-4698, CRITICAL INCIDENT REPORTOnce an incident has been identified as meeting thecriteria for a Major Incident, assure that the health andsafety of all individuals (member, staff and visitors) isaddressed immediately.The Critical Incident Report, Form 470-4698 consists offour distinct parts. Part 1, Initial Report, must becompleted and submitted by the end of the nextcalendar day following the incident.Best practices recommend that an incident report becompleted and submitted up to seven calendar daysfollowing an incident. If sections 2, 3 and 4 cannot becompleted because necessary investigative activitiesare not yet complete and / or resolution activities havenot been implemented, then the incident resolutionshould be updated and completed within 30 calendardays following the incident.The Critical Incident Report, Form 470-4698 can beused to record multiple incident types if they relate tothe same overall incident. If there are two distinctly separate incidents, two forms must be completed. The observer ofthe incident (or the staff involved) completes the Critical Incident Report, Form 470-4698 for any situation that meetsthe definition for a Major Incident. If the incident was not observed, the first person to become aware of the incident (orthe first staff to become aware) completes the report. When there is more than one member involved in the incident, areport will be completed for each member. The report for each member will focus on the actions of that person and thesteps taken by the provider on behalf of that person.Page 5
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