Policy and Procedures

Transcription

1 Policy and Procedures DEPARTMENT NAME: Quality Management SUBJECT: POLICY NUMBER: QM-043 APPROVAL: EFECTIVE DATE: REPLACES : DC-002, dated 11/15/08 I. PURPOSE: To establish Children's Network of Southwest Florida (CNSWFL) procedures for identifying and reporting information related to client risk prevention incidents. II. REVIEW HISTORY: CFOP 215-6, dated 11/1/98 was replaced with CNSWFL s DC- 002 dated 2/17/05 and updated on 10/20/05, 12/26/07, and 11/15/08. III. CONTACT: Quality Management Director, CEO, COO, or Community Development Director. IV.PERSONS AFFECTED: Children's Network staff and contracted providers. V. POLICY: A. It is the responsibility of all CNSWFL personnel, case management organization staff, and contracted provider staff to promptly report all incidents in accordance with the requirements of these procedures. B. This reporting system does not replace existing abuse, neglect and/or exploitation reporting requirements. Allegations of abuse, neglect or exploitation must still be reported to the Florida Abuse Hotline as required by law. C. This operating procedure does not replace the investigation and review requirement provided for in Department of Children and Families CFOP , Child Death Review Procedures. VI. RATIONALE: This policy provides a way to assure management of CNSWFL is aware of critical incidents in a timely manner. It also clarifies which events must be reported. VII.CROSS REFERENCES: Department of Children and Families Operating Procedures 215-6, and Client Risk Prevention, November 1,

2 1996. Florida Statutes Chapter 110. CFOP & CFOP Incidents that Require Inspector General Notification, CFOP Child Death Review Procedures. Department of Children & Families Regional Operating Procedure VIII. DEFINITIONS: A. Client injury or illness. A medical condition or injury of a client under supervision of the CNSWFL or in the custody of the Department which requires medical treatment by a licensed health care professional. A report is required if an injury is sustained or allegedly sustained due to an accident, act of abuse or other incident occurring while in the presence of, or becomes known to, an employee of the CNSWFL or staff member of a contracted agency. B. and Analysis System (IRAS). IRAS is the Department of Children & Families (DCF : Department) s web-based incident reporting system and allows for the timely notification of critical incidents, provision of details of the incident and immediate actions taken, and the ability to track and analyze incident-related details. IRAS is not a case management system and cannot be utilized to capture ongoing and specific case management information, such as the progression of events and action. C. Licensed health care professional. For the purposes of this operating procedure, a person who is licensed to practice medicine pursuant to Chapter 458, F.S. or licensed as a nurse practitioner pursuant to Chapter 464, F.S. D. Theft. The act of stealing by an employee of CNSWFL or a contracted provider client, as described in Exhibit #2. E. Critical Incident. All client-related incidents that result in serious harm or injury to staff or other clients, or a critical incident such as an employee (or provider) felony arrest. A critical incident is the most severe type of incident that impacts the CNSWFL to the greatest extent or as defined in DCF Region policy, ROP Critical Incidents to be Reported: 1. Child-on-Child Sexual Abuse. Any sexual behavior between children which occurs without consent, without equality, or as a result of coercion. This applies only to children receiving services from the Department or by a licensed contract provider, i.e. children in foster care placements, residential treatment, etc. 2. Child Arrest. The arrest of a child in the custody of the Department. 2

3 3. Client Death. A person whose life terminates due to or allegedly due to an accident, act of abuse, neglect, or other incident occurring while in the presence of an employee, in a CNSWFL operated or contracted facility or services center, while under the supervision of the CNSWFL or in the custody of the Department when a death review is required pursuant to Department of Children and Families operating procedure , Child Death Review Procedures. See Section IX. A. 4. for procedures related to child deaths. 4. Elopement\ Missing Child. When the whereabouts of a child in the custody of the Department and under the supervision of the CNSWFL are unknown and attempts to locate the child have been unsuccessful. The unauthorized absence beyond four hours or other time frames as described by the Children s Network policy QM-006. See Section XI.B Employee Arrest. The arrest of an employee of CNSWFL or contracted, subcontracted, or licensed service provider for a civil or criminal offense. Concerns of employee criminal activity shall be reviewed for a referral to the Office of the Inspector General for further investigation. Special attention should be paid to arrests made for a potentially disqualifying offenses, or arrests which occurred while in the performance of an employee s official duties. 6. Employee Misconduct. Work-related conduct or activity of the Department s contracted, subcontracted, or licensed service provider that results in potential liability for the Department; death or harm to a client; or results in a violation of statute, rule, regulation, or policy. This includes, but is not limited to, misuse of position or state property; falsification of records; failure to report suspected abuse or neglect; contract mismanagement; or improper commitment or expenditure of state funds. Concerns of employee criminal activity shall be reviewed for a referral to the Office of the Inspector General for further investigation 7. Escape. The unauthorized absence of a client who is committed by the court to a State mental health treatment facility pursuant to Chapter 916 or Chapter 394, Part V, Florida Statutes.. 8. Security Incident Unintentional. An unintentional action or event that results in compromised data confidentiality, a danger to the physical safety of personnel, property, or technology resources; misuse of state property or technology resources; and/or denial of use of property or technology resources. This excludes instances of compromised client information. Concerns of employee criminal 3

4 activity shall be reviewed for a referral to the Office of the Inspector General for further investigation 9. Significant Injury to Clients of the CNSWFL or in the custody of the Department experiencing a severe medical condition or injury in a treatment/service program that requires immediate medical or surgical evaluation or treatment in a hospital emergency department to address and prevent permanent damage or loss of life. 10. Significant Injury to Staff. Any serious bodily trauma received by a staff member as a result of work-related activity that requires immediate medical or surgical evaluation or treatment in a hospital emergency department to prevent permanent damage or loss of life. 11. Suicide Attempt. A potentially lethal act which reflects an attempt by an individual to cause his or her own death as determined by a licensed mental health professional or other licensed healthcare professional. Note that these incidents should only be reported if the attempt happened while the client was in the physical custody of the Department or a Department contracted service provider, or was receiving child welfare, substance abuse, or mental health services at the time of the incident. 12. Sexual Abuse/Sexual Battery. An allegation of unsolicited or nonconsensual sexual activity by one client to another client or a client to an employee, or any sexual activity between an employee and a client regardless of the consent of the client. For the purposes of this operating procedure, a client is defined as a dependent child in out-ofhome care or receiving services in the home, or an adult residing in residential program or treatment facility for the provision of mental health and/or substance abuse services, or an adult receiving outpatient substance abuse and/or mental health services from a provider funded or licensed by the Department or a Managing Entity. 13. Other Incidents. The following incident types are not included in IRAS and cannot be specifically designated using the Department s incident reporting system. However, the Department of Children & Families SunCoast Region has determined that these incidents are important to our overall risk management processes and/or may be indicative of issues needing to be addressed. These incidents should be reported in IRAS using the incident type of Other. (Revised September 26, 2011 ROP OPR: Performance and Planning 4) a. Bomb or Biological/Chemical Threat. Any threat of harm to property or persons involving a biological/chemical agent or 4

5 explosive device received in person, in writing, by telephone, electronically or otherwise. b. Media Coverage. Media coverage or threat of public reaction that may have an impact on the Department s ability to protect and serve its clients, or other significant effect on the Department or the CNSWFL. Incidents with media coverage or potential media coverage require the appropriate entry on the IRAS Media Involvement field. IX. PROCEDURES: A. Critical Incidents Requiring Immediate Notification: 1. In responding to an incident, an employee s first obligation is to ensure the health, safety, and welfare of all individuals involved. 2. The Department of Children and Families and the Children's Network of Southwest Florida shall receive notification immediately, or within timeframes commensurate with the criticality of events, generally no later than three hours from discovery, of the following critical incidents, as defined in this procedure and ROP revised September 26, Client Death (see paragraph IX. A. 4.) Child-on-Child Sexual Abuse. Sexual Abuse/Sexual Battery. Potential Media Coverage. 3. Upon receiving oral or telephonic notification of any critical incident requiring immediate notification, the supervisor / manager should, in an abundance of caution, notify the Children s Network CFO, COO and DCF s Community Development Administrator within three hours so that appropriate steps can be initiated to mitigate the situation in advance of a more detailed review of the facts. In the incident occurs after business hours, the CEO should be called immediately. 4. Client Death a. Child deaths that fall within the scope of CFOP , Child Death Review Procedures, are reported according to the requirements of Part 10(b) of that procedure. This requires immediate oral notification followed by written notification within one working day for: i. any child death that involves allegations of abuse or neglect, or ii. any child death discovered during the course of an investigation, or iii. any child who was receiving protection services at the time of death. 5

6 b. When a death review is required pursuant to CFOP , Child Death Review Procedures, all child deaths should be considered a critical incident requiring immediate notification to the Department. c. When reporting a client death in the IRAS (see ROP 215-4), the manner of death will be one of the following: i.accident. A death due to the unintended actions of one s self or another. ii.homicide. A death due to the deliberate actions of another. iii.natural Expected. A death that occurs as a result of, or from complications of a diagnosed illness for which the prognosis is terminal. iv.natural Unexpected. A sudden death that was not anticipated and is attributed to an underlying disease either known or unknown prior to the death. v.suicide. The intentional and voluntary taking of one s own life. vi.undetermined. The manner of death has not yet been determined. vii.unknown. The manner of death was not identified or made known. B. Critical Incidents Requiring Routine Notification 1. In responding to an incident, an employee s first obligation is to ensure the health, safety, and welfare of all individuals involved. 2. Immediately, but no later than one hour upon becoming aware of an incident as described in the definitions, every employee of the CNSWFL or contract provider is responsible for reporting such an event, first, by notifying his/her immediate supervisor of the incident orally or by telephone, then, by completing the Incident Report form (Exhibit #1). In the event the direct supervisor is unavailable, the employee is to continue up the chain of command until the employee is able to reach a supervisor or manager and provide that individual with an oral report of the reportable incident in advance of the preparation of the written incident report. 3. Within 2 hours of notification of the incident, the supervisor shall notify the next level in his or her chain of command. This notification shall take place by telephone or face-to-face. 4. Within 8 business hours of the initial notice of the incident, the incident report shall be transmitted to the Quality Management Department of CNSWFL. 5. Within 24 hours, or by close of the next business day, CNSWF staff is responsible for entering the incident into the IRAS system. 6

7 6. If the incident occurs outside of working hours, the CNSWFL Quality Management Department, the Department's Community Development Administrator and the client's child welfare case manager (if applicable) should be notified as soon as possible by phone or fax the next working day unless the incident is one requiring immediate notification. The electronic report notification may be extended to 9:00am the following work day at the discretion of the quality management department, based upon the need for immediate intervention. 7. In addition, all incident reports should be reviewed and transmitted directly to the CNSWFL's Quality Management Department, the Department's Community Development Administrator and the client's child welfare case manager (if applicable) by the employee's immediate supervisor, if available. If the supervisor is not available, the employee should transmit the form to the CNSWFL's Quality Management Department, the Department s Community Development Administrator and the client's child welfare case manager (if applicable) by facsimile transmission device, electronic scanning, or hand deliver, if practical. 8. A copy of the incident report shall be maintained in the employee's work unit by the unit supervisor. Unrelated children will need to be listed on a separate incident report, (i.e.: if two or more clients are involved in an incident and they are not related, a separate incident report will be done for each child involved). In order to preserve confidentiality, use initials for clients other than the one who is the subject of the report. 9. Upon receipt and review of the incident report by the CNSWFL, a determination w i l l b e m a d e for the need for follow-up. If there is a medical injury that requires treatment by a licensed practitioner then there will be follow-up of the incident within 72 hours. For all other incidents there will be a suspense date established to assess the following: a. Staff compliance with program policy and procedure. b. Appropriate handling of the situation and action taken to protect the staff/client. c. Steps taken to maintain control of the situation and to limit further liability of the CNSWFL and its contract providers. d. The arrangement for appropriate medical care and following up on recommendations made by the medical care provider. e. Notification of law enforcement if deemed necessary. f. Notification of the Inspector General if deemed necessary. 7

8 10. Missing children. a. An incident report must be completed and sent within 8 hours to the Department s Community Development Administrator and the CNSWFL s Quality Management Department for children who have been reported as missing. If there are exigent circumstances the incident report on the child must be faxed immediately. Refer to Policy QM-006 for complete instructions on missing children reporting. b. The Child Welfare Case Manager must notify Parents, Guardian Ad litem, Attorney Ad litem, Therapist and Child Welfare legal Services within 24 hours from discovery. 11. Certain incidents as defined in CFOP 180-4, dated 10/29/2007, shall be reported to the Office of Inspector General as described in Exhibit #2, in addition to CNSWFL. C. All critical incidents shall be included on the and Analysis System (IRAS) as required by ROP The Incident Report shall be transmitted within 24 hours (or sooner, as requested) to the Department s Community Development Administrator, Children's Network Chief Operating Officer, appropriate Child Welfare Case Managers and contracted service providers. Report shall include as much specific information as is known at the time; follow up and/or corrective action information shall be transmitted as appropriate or requested by the Quality Management Department. During evening hours or weekends, the electronic report notification may be extended to 9:00am the following work day at the discretion of the Quality Management Department, based upon the need for immediate intervention. D. As soon as the written incident report is available, it should be faxed to the CNSWFL's Quality Management Department and the Department s Community Development Administrator. The supervisory review of the incident report is intended to ensure completeness of information and coordination of appropriate corrective action and follow-up to protect the client from further risk or injury and to manage activities to control the situation. 8 E. Requests for copies of incident reports 1. Any request by the public or media for a copy of an incident report should be directed to the Director of Resource Development/Communications at the CNSWFL in order to assure all legal requirements are met. 2. CNSWFL s Director of Resource Development/Communications will collaborate with the Communications Officer at the Department of Children

9 and Families to coordinate pertinent information that would be released under public records law. Information will, at a minimum, answer the following questions: who; what; when; and where. 3. Contract managers and licensing personnel should review and consider incident reports for the 12 months prior to renewal when re-licensing a home or facility or renewing a contract. 4. Subsequent requests for corrective action plans, status reports or additional information may be initiated on an individual basis as determined by the situation. X. EXHIBITS A. Form B. Reporting to the Office of the Inspector General 9

10 EXHIBIT #1 Original Date when the form was completed: Person completing form: Contract Provider s name: Follow-Up Only When you became aware of the incident: Date Time County: Name of Facility/Site where the event occurred : Address of Facility/Site where the event occurred: 8 H R S M A X Date & Time of Incident: Law Enforcement Notified: Yes Date No Police report # issued: Yes No If yes, Police Report #: CATEGORIES Critical Events Abuse Hotline called Yes No Immediate Critical Events Child arrest Suicide Attempt Client Death (See CFOP ) Employee Misconduct /Arrest Missing child / Escape Sexual Abuse / Sexual Battery Security incident Unintentional Significant Injury to Staff Significant Client Injury/Illness Bomb / Biological/ Chemical (Potential Media Event) Employee events reportable to Inspector General Other Event Child on Child Sexual Abuse Potential Media Event 3 H R S M A X DESCRIPTION OF INCIDENT Include factual information only. Use additional page if necessary. If this is a missing child report add: (1) Clothing Description (2) Direction of traveling (3) Possible destination 10

11 IDENTIFYING INFORMATION Use initials for clients other than the one who is the subject of the report. Unrelated children will need to be listed on a separate incident report. Persons Involved: First Name Last Name Child/Adult Date of Birth Relationship to Agency **If the person completing the form is not the CMO case manager/ supervisor, please indicate date and time when CMO case manager was notified Notification process Incident report sent on: Cc: Child s Case Manager**: Date: Time: Cc: Immediate Supervisor: Date: Cc: Children s Network of SW Florida Date: Cc: Circuit Administration (239) Date: What measures have been taken to protect the client and to gain control or manage the situation? Instructions for Completing the Incident Report Form: 1. FAX completed form to DCF Circuit Administration at: (239) , and fax to Children s Network, Attention: Q.M Administrative Assistant at (239) Follow-up only check when this report is additional information about a situation previously reported. Each incident report will be numbered for informational purposes. 3. County county where incident occurred. 4. Contract Provider -- provider who is providing services to the client. 5. Categories refer to incident reporting matrix procedures for definitions of these categories (Check one or more) 6. Description of Incident Type this information (preferred) or print clearly. Use full names and only report facts. Identifying information will be redacted if there is a public records request. 7. Identifying Information First and Last Names; A for Adult or C for Child. Place DOB or age if DOB is unknown. Indicate if the incident involves a client, staff or other. 8. Notification Process: The Person completing the form is to ensure that the incident report is CC, unless this responsibility has been designated. The case manager CC must include date and time. 11

12 12 EXHIBIT #2 REPORTING TO THE OFFICE OF THE INSPECTOR GENERAL Per CFOP (dated October 29, 2007), the incidents listed below may warrant a full investigation by the Office of the Inspector General (OSIG). As such, they shall be reported to the IG by the Regional Managing Director or designee. This shall occur no later than two days of discovery by staff in the region, unless a different timeframe is specified. Notification may be made by completing a Notification/Investigation Request (form CF 1934 (electronic version in EForms)) and ing the request to the Office of Inspector General. A request for investigation can also be made by mailing the completed form to the Office of Inspector General, 1317 Winewood Boulevard, Building 5, 2nd Floor, Tallahassee, Florida, ; or via fax at (850) The report should be accompanied by other relevant backup documentation (e.g., police report). Accompanying documents may need to be submitted subsequent to the initial report in order to meet the specified notification time frame. 1. Employee negligence that results in client injury, abuse, neglect or death immediately upon verification by the district or program office; 2. Fraud; 3. Theft; 4. Breaches of confidential information by an employee, unless inadvertent and selfreported (e.g., revealing a reporter s name, providing confidential documents to unauthorized persons, access of client files for non-business reasons, providing information from client files such as medical or benefits information, etc) immediately upon confirmation by the district; 5. Falsification of official records (e.g., intentional alteration of state documents, misrepresentation of information during an official proceeding, intentional falsification of client case records, case notes, client contact reports, visitation records, or client home visits, creating false and fictitious files, etc.); 6. Misuse of position or state property, employees, equipment or supplies for personal gain or profit (e.g., soliciting on state time and state property, conspiracy to conceal missing state property, misuse of the Internet to conduct personal business as defined by policy, etc.); 7. Failure to report known or suspected neglect or abuse of a client; 8. Improper expenditure or commitment of public funds; 9. Computer related misconduct (e.g., accessing FLORIDA, Florida Safe Families Network (FSFN) system files of clients when there is no direct business involvement with the client, accessing inappropriate or pornographic web sites, sending threatening or harassing messages, misuse of , etc.); 10. Miscellaneous (e.g., retaliation, unauthorized weapon on state property, criminal arrest of employee, etc.); 11. Any violation under 435, F.S., Title XXXI, Employee Screening, that would result in disqualification from client contact duties (e.g., convicted of murder, manslaughter, assault and battery, kidnapping, false imprisonment, sexual battery, theft, robbery, child abuse, abuse and neglect of an elderly or disabled adult, sale of a controlled substance, resisting arrest, contributing to delinquency of a minor, or other disqualifying offense); or, 12. Any other wrongdoing that would be a violation of statute, rule, regulation or policy, exc