Top Banner
Division of Mental Health and Addiction Critical Incident Reporting Policy and Procedure June 2019
17

Division of Mental Health and Addiction Critical Incident ... · Division of Mental Health and Addiction Critical Incident Reporting Policy and Procedure June 2019. Agenda •Purpose

Jun 02, 2020

Download

Documents

dariahiddleston
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Page 1: Division of Mental Health and Addiction Critical Incident ... · Division of Mental Health and Addiction Critical Incident Reporting Policy and Procedure June 2019. Agenda •Purpose

Division of Mental Health and Addiction

Critical Incident Reporting

Policy and Procedure

June 2019

Page 2: Division of Mental Health and Addiction Critical Incident ... · Division of Mental Health and Addiction Critical Incident Reporting Policy and Procedure June 2019. Agenda •Purpose

Agenda

• Purpose and objectives• Types of incident reports• Reporting Requirements• Quality Assurance• Wrap-up and Questions

Page 3: Division of Mental Health and Addiction Critical Incident ... · Division of Mental Health and Addiction Critical Incident Reporting Policy and Procedure June 2019. Agenda •Purpose

Purpose

Incidents will happen… Staff and Consumer safety

• How do you respond, report, resolve and remedy Federal and State Mandates

Objectives

Know how to complete incident reports Understand the changes for reporting

Page 4: Division of Mental Health and Addiction Critical Incident ... · Division of Mental Health and Addiction Critical Incident Reporting Policy and Procedure June 2019. Agenda •Purpose

Types of IncidentsResidential Settings Community Based/Client’s Home

Fire requiring a local fire department response

Injury

Any emergency rendering the residence temporarily or permanently uninhabitable

A suicide/suicide attempt by a resident

Any serious injury of a resident requiring professional medical attention

Death

Suspected or alleged exploitation, neglect or abuse

Homicide

A suicide/suicide attempt by a resident Medication Error

Incident involving the resident requiring a police response- Assault on staff/client

Suspected or alleged exploitation, neglect or abuse

Medication Error

Elopement

Seclusion and Restraint

Death

Page 5: Division of Mental Health and Addiction Critical Incident ... · Division of Mental Health and Addiction Critical Incident Reporting Policy and Procedure June 2019. Agenda •Purpose

Critical Incident ReportingRequirements

Page 6: Division of Mental Health and Addiction Critical Incident ... · Division of Mental Health and Addiction Critical Incident Reporting Policy and Procedure June 2019. Agenda •Purpose

Reporting Time Frames

• Residential Settingso Within 24 hours

• Outpatient/Community Setting/Client’s Homeo Within 72 hours of CMHC being notified

Resource: State Plan Amendment (SPA) and Article 7.5 Residential Living Facilities for Individuals with Psychiatric Disorders or Addictions

***Now Active***CIR Portal ChangeIdentify reason the incident was not reported within required timeframe

Page 7: Division of Mental Health and Addiction Critical Incident ... · Division of Mental Health and Addiction Critical Incident Reporting Policy and Procedure June 2019. Agenda •Purpose

Required InformationAbuse, Neglect and/or Exploitation Medication Errors

Names of those involved in the incident and relation to victim

How was the incident addressed

Was Adult Protective Service (APS) contacted Describe the preventative measures to decrease likelihood of incident reoccurring

Describe how the client will be kept safe during the investigation

Title/Credentials of staff completing incident report

If the accusation was against the staff, how was that handled

Describe reason the CIR was not submitted within required time frame (24 vs. 72 hours)

Describe the preventative measures to decrease the likelihood of incident reoccurring

When the doctor was contacted, what were the instructions to staff and/or client to address possible medical concerns or adverse drug responses

Describe reason the CIR was not submitted within required time frame (24 vs. 72 hours)

How was the incident resolved

Title/Credentials of staff completing incident report

Page 8: Division of Mental Health and Addiction Critical Incident ... · Division of Mental Health and Addiction Critical Incident Reporting Policy and Procedure June 2019. Agenda •Purpose

Critical Incident Reporting Compliance

Page 9: Division of Mental Health and Addiction Critical Incident ... · Division of Mental Health and Addiction Critical Incident Reporting Policy and Procedure June 2019. Agenda •Purpose

0%

20%

40%

60%

80%

100%

Qtr 1 Qtr 2 Qtr 3 Qtr 1 Qtr 2 Qtr 3 Qtr 4

48%

75%83%

60% 55%

74%58%

SFY 2019

CRITICAL INCIDENT REPORTING

SFY 2018

Reporting ComplianceProvider Goal: 86%

22%

58% 59%

0%

10%

20%

30%

40%

50%

60%

70%

SPY 1 SPY 2 SPY 3

3 YEAR REPORT2014-2017

SPY= State Plan Year

Page 10: Division of Mental Health and Addiction Critical Incident ... · Division of Mental Health and Addiction Critical Incident Reporting Policy and Procedure June 2019. Agenda •Purpose

Critical Incident Quality Assurance Processes

Page 11: Division of Mental Health and Addiction Critical Incident ... · Division of Mental Health and Addiction Critical Incident Reporting Policy and Procedure June 2019. Agenda •Purpose

Compliance Process: How will it work?

• BPHC: Begins September 1, 2019• AMHH: Begins October 1, 2019• Each CMHC will receive a report of their compliance scores for each quarter• Report will be provided 15 days from end of quarter

• Including any additional follow-up forms provided to the CMHC

BPHC Quarters AMHH Quarters1st June 1- August 30 1st October 1- December 312nd September 1-November 30 2nd January 1-March 313rd December 1-February 28 3rd April 1-June 304th March 1-May 31 4th July 1-September 30

Page 12: Division of Mental Health and Addiction Critical Incident ... · Division of Mental Health and Addiction Critical Incident Reporting Policy and Procedure June 2019. Agenda •Purpose

Resource: 405 IAC 1-1.4-4 Sanctions against providers; determination after investigation

Informal Adjustment (IA)

After first 90 day non-compliant CIR review:• Verbal or email guidance to the provider and the primary

contact or provider supervisor as deemed most appropriate by QA/QI staff.

• DMHA will provide data to show compliance issues including incident date and staff member that submitted CIR

Page 13: Division of Mental Health and Addiction Critical Incident ... · Division of Mental Health and Addiction Critical Incident Reporting Policy and Procedure June 2019. Agenda •Purpose

After second 90 day non-compliant CIR review• A “Formal Notice” is sent via email (with read receipt or

including a request to respond confirming receipt) to the CEO and identified primary contact of the provider

• DMHA will provide data to show compliance issues including incident date and staff member that submitted CIR

• The education letter will identify the next steps if a third 90 day non-compliance review occurs.

Educational Letter (EL)

NOTE: If after two quarters since EL, compliance falls below 86%, an Informal adjustment will be issued again

Resource: 405 IAC 1-1.4-4 Sanctions against providers; determination after investigation

Page 14: Division of Mental Health and Addiction Critical Incident ... · Division of Mental Health and Addiction Critical Incident Reporting Policy and Procedure June 2019. Agenda •Purpose

This occurs after the third 90 day non-compliant CIR review

DMHA Notice: A “Formal Notice” letter written on FSSA letterhead

requiring corrective action and an accompanying Corrective Action

Plan (CAP) are sent to the provider for response.

The CAP must include the following information: Responsible party Timeframe for completion A way for DMHA to verify the CAP has been completed Plan to prevent reoccurrence Be effective

Corrective Action Plan

NOTE: If after two quarters since CAP, compliance falls below 86%, an Educational Letter will be issued again

Resource: 405 IAC 1-1.4-4 Sanctions against providers; determination after investigation

Page 15: Division of Mental Health and Addiction Critical Incident ... · Division of Mental Health and Addiction Critical Incident Reporting Policy and Procedure June 2019. Agenda •Purpose

Additional Action Steps

• Mandatory re-trainings • Increase visits based on progress• Increase request for documentation• Staff member must be re-trained before providing service going

forward

Resource: 405 IAC 1-1.4-4 Sanctions against providers; determination after investigation

Page 16: Division of Mental Health and Addiction Critical Incident ... · Division of Mental Health and Addiction Critical Incident Reporting Policy and Procedure June 2019. Agenda •Purpose

• Decertification of specific staff members• Referral to FSSA Audit • Program Integrity

Graduated Sanctions

Resource: 405 IAC 1-1.4-4 Sanctions against providers; determination after investigation

Page 17: Division of Mental Health and Addiction Critical Incident ... · Division of Mental Health and Addiction Critical Incident Reporting Policy and Procedure June 2019. Agenda •Purpose