INCIDENT REPORTING - Cardinal Innovations Healthcare Solutions

INCIDENT REPORTINGhttp://www.cardinalinnovations.org/qm/

DisclaimerInformation provided in this presentation pertains only to thecounties in the Cardinal Innovations Healthcare Solutions Region.This information is specific to the Cardinal Innovations Region andmay not apply to other LME, MCOs, providers, stakeholders orindividuals outside the Cardinal Innovations catchment area.Presentation slides are brief, bullet-points of information andshould not be used out of context.Copyright © 2013 Cardinal Innovations Healthcare Solutions. All rights reserved.

WHAT IS AN INCIDENT?An incident is any occurrence which is not consistentwith the routine operation of a facility or service, or theroutine care of a consumer, that is likely to lead toadverse effects upon a consumer. 10A NCAC 27G .0103(b)(32)Incident Reporting and Monitoring of facilities/servicesis required by NC General Statues. 10A NCAC 27G .0600-.0610

PURPOSE• Ensure serious adverse events are addressedquickly• Analyze for ways to prevent futureoccurrences• Improve service system• Data collection

WHO IS REQUIRED TO REPORT?CATEGORY A PROVIDERSProviders of publicly funded services licensedunder NC General Statutes 122C, except Hospitals.CATEGORY B PROVIDERSProviders of publicly funded non-licensedPeriodic or community-based MH/DD/SASServices.

HOME & HOST DEFINITIONSHOME LME:• Where the consumer first entered service ortheir family home• County where Medicaid was establishedHOST LME:• Location of service provision

INCIDENT LEVELSLevel I:No significant threat to health and safetyLevel II:Threat to health and safety of a consumer or othersLevel III:Results in Death / permanent physical /psychological impairment to or by a consumer

INCIDENT TYPES• Consumer Death• Restrictive Intervention• Consumer Injury• Abuse/Neglect/Exploitation• Medication Error• Consumer Behavior (Suicidal Behavior/SexualBehavior/Consumer Aggressive Act/Consumer Absence)• Suspension• Expulsion• Fire• Search and Seizure• Confidentiality Breach

RESTRICTIVE INTERVENTIONS• Submission Required if:• Used in an unplanned/emergency situation• Planned but administered improperly• Planned but resulting in discomfort, complaint, death orinjury requiring treatment by a licensed health professional• Required transition from emergency to planned:• After the 3 rd restraint has occurred in a calendar month. A4 th restraint should not be utilized until there is a CardinalInnovations Approved Planned Intervention• Submit plans to UM via updated Person Centered Plan• Refer to UM Communication Bulletin FY-1011-UM-08

INCIDENT RESPONSE IMPROVEMENTSYSTEM (IRIS)• IRIS is a Department of Health and Human Services(DHHS) web based incident reporting system for reportingand documenting responses to Level II and Level IIIincidents.• The purpose of IRIS is to provide a consistent process forall MH/DD/SAS providers receiving public funds to reportincidents in a timely manner.• IRIS Website: https://iris.dhhs.state.nc.us/

REPORTING FORMS• DHHS incident reporting forms should only be used (faxedto LME/MCO) when IRIS is not available• The data should be entered into IRIS when IRIS becomesavailable• Forms are available on the NC DMH/DD/SAS website:http://www.ncdhhs.gov/mhddsas/statspublications/Forms/index.htm

SUBMISSION REQUIREMENTS• All incidents must be documented andsubmitted within the required timeframe• Staff with the most knowledge about theincident should complete the report

THE MANUAL IS YOUR FRIEND• Incident Response and Reporting Manual (February 2011)• IRIS Technical Manual (June 2010)

INCIDENT RESPONSE & REPORTING MANUAL• Pg. 6 - IRIS availability• Pg. 7 - “Under Your Care”• Pg. 8 - Illness of a consumer• Pg. 8 - Consumer Deaths• Pg. 9 - Internal Team Review• Pg. 9 - Consumer Injury• Pg. 10 - Abuse/Neglect/Exploitation Reporting• Pg. 10 - Incidents of Concern for the Community• Pg. 11 - Self-administration medication errors• Pg. 12- Consumer Behavior• Pgs. 20-25 - Criteria for determining level of response toincidents

PERIODIC SERVICES AND INCIDENTREPORTING• Death and Abuse/Neglect/Exploitation should be reported by all providersregardless of if services were being provided at the time of the incident or if theconsumer is “under the care” of the provider at the time of the incident.• Medication Errors: Periodic service providers are required to submit medicationerror incident reports only if the provider is responsible for the administration orsupervision of medications. However the provider should also follow their agencyprocedure regarding reporting medication errors.• Consumer Behavior: Report any consumer acts that are reported to lawenforcement in any of the following situations (pg. 12 Incident Response andReporting Manual):• If the incident occurs when you are actively engaged in providing services, or• If the incident is related to the reason the individual is in treatment, or• When you learn of the legal involvement of the individual

IRIS GENERAL GUIDELINES• Providers do not need a user ID or password to access IRIS.• Complete mandatory items based on the type of incident that occurred. Mandatoryitems are indicated by red stars beside the item.• It is essential to save information at the end of each information tab.• Enter your agency’s email address when completing the report.• DO NOT share your incident number with anyone outside of your agency,including LME/MCO staff.• LME/MCO staff will need the following information to instruct IRIS to send anincident number: Name of staff entering the report, Consumer Name, and IncidentDate.• Attaching Documents: Supporting documents should be uploaded electronically:• Do not password protect attached documents• Attached documents can not be removed once uploaded.

COMMON ERRORS• Provider Comments left blank• Comments Icon• Incorrect Date of Birth• Incorrect home and/or host LME• Incident type not identified (injury, behavior, etc.)• Reminder: multiple incident types can be selected• Restrictive Intervention section left blank or incomplete• Authorities contacted section left blank• Incomplete HCPR section• Incident date and date provider learned of the incident

AUTHORITIES CONTACTEDDepending on the type of Incident, the following authoritiesshould be contacted:Notified by the provider/person completing report– DSS (Abuse/Neglect/Exploitation)– Law Enforcement Agency– Parent/Guardian– Clinical Home/Treatment Team MembersNotified by IRIS:– Division of Health Service Regulation (DHSR)– Healthcare Personnel Registry (HCPR)– Home and Host LME

THUMBS UP ICON• The provider staff can enter and save the information but the supervisor shouldreview and submit the report.• A document can be saved for up to 72 hours as long as it has the mandatoryinformation. You can return later, add additional information and then submitthe incident report.• If the report is not submitted within 72 hours of the incident report beingstarted, the LME/MCO will receive an alert that the provider has an incidentreport that has not been submitted.• Reports are not fully submitted until the “Supervisor’s Action” tab has beencompleted and the “thumbs up” icon is received.Submitted Report =

UPDATING REPORTS• When additional information is obtained the original reportshould be updated and resubmitted.• Use the comment section to note that additional informationwill be submitted.• Updated information must be submitted even if the newinformation does not change the incident level.• QM staff may also request additional information (progressnotes, death certificate, discharge summaries, etc.)*Reminder: The “Supervisor’s Action” Incident Submissiontab must be completed when resubmitting

PLAN OF CORRECTION (POC)ELEMENTS• Identify the issue• Identify the cause• Identify detailed action plan• Identify POC monitoring system• Identify Responsible person• Identify Target date*Attach supporting documentation as needed.

QUARTERLY REPORTS• Providers are required to report aggregate information onLevel I incidents to the Host LME/MCO quarterly:• Restrictive interventions• Medication Errors• Search and Seizures• Reports should be submitted even if there are no level 1incidents to report.• Submit report indicating “0” incidents• A copy of the Quarterly Reporting form can be found on theCardinal Innovations QM website at:http://www.cardinalinnovations.org/qm/qm_forms.asp

FILING INCIDENT REPORTS• Print a copy for your records and maintain theincident report number.• Incident reports are quality assurance administrativeforms and should never be filed in a consumer’smedical record.• Confidentiality: All incident reports are confidentialand protected by G.S. 122C-30, G.S. 122C-31, G.S.122C-191, G.S. 122C-192

IRIS TEST SITE• Do Not Enter Real Information into the testsite• Internal Traininghttps://irisuat.dhhs.state.nc.us/

BACK-UP STAFFING DEFINITIONProvision for alternative arrangements for thedelivery of services that are critical toparticipants well-being in the event that theprovider responsible for furnishing theservices fails to or is unable to deliver them.

BACK-UP STAFFING INCIDENT REPORT• Specific to Innovations Services• Failure to provide back-up staffing is considered aLevel 1 Incident• Do NOT include in quarterly incident report• Completed by the Provider Agency, Agency WithChoice, or Employer of Record• Submitted to Quality Management

PURPOSE• Ensure that if the assigned staff person is unable toprovide the service, another qualified person isavailable in the staff member’s absence• Ensure participant’s needs are met• Ensure health, safety and welfare of participant

REPORT SUBMISSION• When staff is absent or not present to provide theservice and no back up staff is provided• When staff is absent or not present to provide theservice and the family declines the back up staffingoffered• When staff is absent or not present to provide theservice and the consumer’s employer declines theback up staffing offered* Fax to the corporate office at (704) 939-7906

QM REVIEW• QM Department reviews the incident report to ensurethat any issues that affect the health and safety of aparticipant are addressed and appropriate follow-upoccurs.• Quality Management Department may requireadditional training and/or a corrective action plan.• If the participant’s health and safety has beenjeopardized by an agency, the Quality ManagementDepartment will make appropriate notifications

BACK-UP STAFFING VS. SERVICEDEVIATIONService Deviation:– Assigned Staff is available, however consumer isnot available– Consumer/Family is on vacation– Consumer Illness– Holidays– Inclement Weather

BACK-UP STAFFING FORM• Appendix S of the NC Innovations TechnicalGuide, 2012• QM Website:http://www.cardinalinnovations.org/qm/

LOCAL QM CONTACTS• Alamance-Caswell COC QM Manager: Jodi MeachamMain Phone: (336) 513-4222• Five County COC QM Manager: Don ScottMain Phone: (252) 430-1330• OPC COC QM Manager: Lynne HamletMain Phone: (919) 913-4000• Piedmont COC QM Manager: Jill QueenMain Phone: (704) 721-7000