POLICY ON INCIDENT REPORTING AND INCIDENT MANAGEMENT

POLICY ON INCIDENT REPORTING AND INCIDENT MANAGEMENT It is the policy of ACHIEVA to establish procedures for the prevention and management of incidents in accordance with ODP Incident Management Bulletin 6000-04-01. Incident management is the collection, classification and use of incident data to protect those we serve from harm. These procedures outline agency responsibilities that promote the health, safety, rights and dignity of individuals receiving services by providing quality services in a caring and hospitable environment. The primary goal of the incident management policy is to ensure that when an incident occurs, the response will be adequate to protect the health, safety and rights of the individual. The continuous review and analysis of reported incidents at the provider level is to enhance risk management processes and to formulate actions to prevent the recurrence of incidents. Information below has been taken from or adapted from ODP Chapter 6000. Statement of Policy Subchapter Q Incident Management Bulletin 6000-04-01, the ODP Statement of Policy Amendments from the Reissued ODP Communication Packet 031-15 and the Pennsylvania Certified Investigator Manual. I. Reportable Incidents 6000.921. Categories of Incidents The following are the categories of incidents to be responded to by staff who are knowledgeable about incident management processes and protecting individuals. After the immediate health and safety assurances have been met, these incidents are to be reported in HCSIS. The categories are divided into those that must be reported within 24 hours of discovery or recognition and those that are to be reported within 72 hours. For the incidents that require reporting within 24 hours, the first section of the incident report must be completed in HCSIS within 24 hours. The first section includes a minimum data set (individual and provider demographics, action taken to protect the individual and description of the incident and the category of incident). The final section of the incident report includes additional information about the incident, any required investigation and corrective actions. The final section is to be completed within 30 days of recognition or discovery of the incident. The second set of incidents requires reporting within 72 hours of recognition or discovery. These incidents are reported using abbreviated data entry screens in HCSIS. When multiple individuals associated with a provider/entity are involved in certain primary categories or secondary categories, or both, of incidents, the incident can be reported using a site report. Only those events designated in the list of reportable incidents as a site report may be filed in this manner. An individual who is part of a group involved in a site report and is injured must have a separate individual report completed using the proper classification. Providers, supports coordination entities, counties and ODP must be vigilant to report any incident where there is a suspected crime to law enforcement. When an individual is allegedly abused, neglected or the victim of a crime, the individual is to be offered the support of a victim s assistance program. See Appendix G, (relating to victim s assistance programs). 6000.922 Incidents to be filed within 24 hours Employees should refer to ODP Bulletin 6000-04-01 for the definition of each reportable incident. Abuse Physical abuse 1

Psychological abuse Sexual abuse Verbal abuse Improper or unauthorized use of restraint Neglect Injury requiring treatment beyond first aid Death Disease reportable to the Department of Health Emergency closure Emergency room visit Fire Hospitalization Individual-to-individual abuse Physical Psychological Sexual Verbal Law enforcement activity Missing person Misuse of funds Psychiatric hospitalization Rights violation Suicide attempt 6000.923. Incidents to be reported within 72 hours Employees should refer to ODP Bulletin 6000-04-01 for the definition of each reportable incident. Medication error Omission Wrong dose Wrong time Wrong person Wrong medication Wrong position Wrong technique/method Wrong form Restraints Physical Mechanical Chemical II. Role of the Initial Reporter, Point Person, Certified Investigator and Incident Manager 6000.951. Initial Reporter: The initial reporter is any person who witnesses the incident or is the first to discover or be made aware of the signs of an incident. The initial reporter first responds to the situation by taking prompt action to protect the individual s health, safety and rights. The protection may include dialing 911, escorting to medical care, or calling ChildLine, Older Adult Protective Services Act (OAPSA) Agency, or Adult Protective Services (APS) Agency. As soon as the immediate needs of the person have been met, the initial reporter notifies the provider point person of the incident and receives instructions on next steps to take. The initial reporter documents his observations in a narrative report which is kept in the provider/entity s files. In cases of 2

alleged abuse or neglect, the initial reporter will comply with the applicable laws and regulations. See Appendix F (relating to related laws, regulations and policies). 6000.952. Point Person: A point person is assigned and authorized to perform specific duties as described in provider/entity or county policy. In general, a point person is to receive verbal or other reports or allegations of incidents from individuals, families and initial reporters. They are to safeguard the individual, ensure that HCSIS Incident Reports are submitted, communicate with others involved in investigations, follow-up and review of incidents. This role is pivotal in the incident management process. When an incident is reported, the point person, as a representative of the agency, is to: 1. First confirm that appropriate actions have been taken or order additional actions to secure the safety of the individual involved in the incident. 2. Separate the individual from the target when the individual s health and safety may be jeopardized. 3. Ensure notification requirements are met of the: Older Adults Protective Services Act (35 P. S. 10225.101 10225.5102) Child Protective Services Law (23 Pa. C.S. 6301 6384) Adult Protective Services Act (Act 70) 4. Determine whether an investigation or other follow-up is needed. 5. Secure the scene of an incident when an investigation may be required. 6. Ensure that, when needed, a certified investigator is promptly assigned. 7. Notify appropriate supervisory/management personnel within 24 hours of the incident, as specified in provider/entity or county policies. 8. Initiate a HCSIS Incident Report within 24 or 72 hours as described in the Reportable Incident section of this bulletin. 9. Notify the family within 24 hours (72 hours for medication error and restraint) unless otherwise indicated in the individual support plan. 10. If required, verify that a report was submitted to the APS Agency within 48 hours. Acceptable reports include HCSIS or EIM printable incident summaries of the first section submitted. 6000.653. Incident Management Representative: The incident management (IM) representative is the person designated by the provider with the overall responsibility for incident management. This includes the assurance that the activities of the initial reporter and point person have been completed. In addition, the IM representative is responsible for the finalization of the incident report within 30 days of the incident. The IM representative is responsible to evaluate the quality of incident investigations as described in the Pennsylvania Certified Investigators Manual. 6000.954. Certified Investigator: A certified investigator is a person who has been trained and received a certificate in investigation from ODP as communicated via ODP Bulletin 00-01-06, issued September 6, 2001, titled Announcement of Certified Investigator Training. Certified investigators are to promptly begin an investigation, when assigned, and are to enter a summary of their investigation findings in the HCSIS Incident Report. III. Incident Management and Reporting Process Listed below is the suggested order to be followed once an incident is discovered or alleged: 1. The incident is reported or witnessed by the initial reporter. 3

2. Once the initial reporter has taken prompt action to protect the victim s health, safety and rights, he/she then notifies the appropriate supervisor or on-call staff, depending on the date and time the incident occurred and the location of the incident. If applicable, the initial reporter will need to separate the target and the victim. 3. The initial reporter documents his/her observations in a narrative report on an Incident Report form which is kept in the incident file. This written statement must be available for review. 4. The supervisor or on-call staff will then notify the appropriate point person that an incident has occurred. 5. The point person needs to follow all responsibilities and duties as listed above in the Role of the Point Person 6000.952. 6. The point person notifies the incident manager (IM) and/or the appropriate department Vice President or designee that an allegation of an incident has been reported. 7. The IM will ensure that the responsibilities of the initial reporter and point person have been completed. 8. The IM, point person and/or the Vice President of the department or designee will determine if an investigation needs to be initiated and will assign an investigator. 9. The target is to be notified by the point person or the IM that he/she is the target of an investigation. (Note that this is not the responsibility of the Certified Investigator.) At the time of notification, the target should be informed that he/she is suspended pending an investigation. At this time, the target should not be given details of the alleged incident, the consumer s name, or who reported the incident. The target will be informed that a certified investigator will contact them and that they should not contact anyone regarding the alleged incident or the investigation. 10. The point person will file the First Section of the incident report in HCSIS within 24 hours of the incident and will ensure that all notification requirements are met. This would include OAPSA, Childline and/or APS as applicable. 11. The point person or designee will notify family/caregivers and the SC of the incident. Again, the information that is given at this point is that an incident has occurred, an investigation will be conducted and that they will be notified with the results of the investigation when it is complete. 12. The IM representative is responsible for the overall quality of the incident report and for ensuring finalization of the incident report within 30 days of the incident. IV. Incidents Requiring an Investigation According to ODP Bulletin 6000-04-01, the following incident allegations require an investigation: Abuse All categories including improper or unauthorized use of restraint Neglect All categories Rights violation All categories Misuse of funds/exploitation All categories Death when an individual is receiving services from a provider Hospitalization resulting from: Accidental injury Unexplained injury Staff to individual injury Injury resulting from individual-to-individual abuse Injury resulting from restraint ER Visit resulting from: Unexplained injury Staff to individual injury Injury resulting from individual-to-individual abuse Injury resulting from restraint 4

Injury requiring treatment beyond first aid resulting from: Staff to individual injury Injury resulting from individual-to-individual abuse Injury resulting from restraint Individual-to-individual sexual abuse Listed below are the suggested steps that a certified investigator should follow: 1. Speak with the point person. Ensure that the scene has been secured (if applicable). Gather information from the point person in regards to the incident. 2. Determine the Investigatory Question which is designed to: Keep the investigator focused Determine what is relevant Show relationship between time and space 3. Gather all necessary equipment needed to conduct the interviews and to gather evidence. 4. Order of witness interviews: Point Person Initial reporter Victim Direct witnesses Circumstantial witnesses Target 5. Interviewing process: All potential witnesses must be interviewed. Take written statements from everyone interviewed. If a consumer needs help writing you can provide assistance. Complete background interviews if necessary. (To establish a particular pattern of behavior) Complete follow-up interviews to clarify information if other questions arise throughout the course of the investigation. Remember that you have 10 (ten) days to complete all of the interviews but that the initial interview needs to occur within 24 (twenty four) hours from the time you were assigned the investigation. Gather and keep all evidence. This will include any material items that are collected at the scene, any notes that you take or that are taken in the interview and all witness statements. Make sure that all witness statements are signed. 6. Type your Certified Investigation Report (CIR), making sure that in your summary you have answered the Investigatory Question. 7. Discuss your findings with the appropriate people. (Vice President of the department, Point Person, IM, and/or Human Resources when appropriate). You will be notified should the report need amended. 8. Schedule a meeting with the Vice President of the department or designee to review your findings and to complete the Administrative Review. It is always best to complete and submit this report in HCSIS as soon as you have discussed your findings with the appropriate people. 9. Notify the point person once you have finalized the Investigation Summary in the HCSIS report. The point person will then complete and submit the Final Section of the HCSIS report. 10. Place the following in an envelope or folder to be secured in a locked file cabinet at the office: Any physical, demonstrative and documentary evidence that was collected The agency incident report form completed by the initial reporter Any photos, diagrams, etc. All signed witness statements Your typed Certified Investigation Report Any notes that you may have taken during the course of the investigation Give everything to the IM representative to be filed at the office 5

The IM must review and finalize the HCSIS report within 30 (thirty) days of the incident. It is also the responsibility of the point person or designee to notify the target of the result of the investigation. At times, it may be necessary to involve Human Resources in this notification process. A determination will be made as to who will be responsible for notifying the SC and family or caregiver of the results of the investigation. V. Peer Reviews Peer Reviews are the process of measuring the quality of investigations. The Certified Investigation Peer Review (CIPR) tool is utilized to document the assessment of the investigation. In its most fundamental use, the CIPR is an indicator in assessing the quality of investigations from a peer or supervisory perspective and to provide performance feedback directly to the Certified Investigator. Peer reviews will be held four times a year in January, April, July and October. The peer review team will review at least 10% of the investigations that occurred in the previous three month reporting period. All required paperwork will be completed by the reviewers and kept on file in the office. A copy of the peer review findings will be given to the appropriate investigator. Peer reviews are designed to aid the Certified Investigator to perform more accurate and thorough investigations. VI. Related Laws, Acts and Regulations Information below has been taken from or adapted from the ODP Statement of Policy Amendments from the Reissued ODP Communication Packet 031-15, Appendix F. In addition to the reporting methodologies described in this statement of policy, the following is provided as a guide to assist in identifying additional reporting. This does not fully define, nor is it intended to substitute for, the applicable statutes and regulations. Reportable incidents that occur in facilities licensed by the Department of Human Services, involving individuals whose support needs are not funded through the Commonwealth or county intellectual disability systems, are to be reported to whomever funds the individual s support and to the Commonwealth/Regional Office of Developmental Programs. This includes individuals from other states, individuals who are funded by agencies not part of the intellectual disability system and individuals whose support needs are privately funded. The Child Protective Services Law (23 Pa. C.S. 6301-6385) The Child Protective Services Law (CPSL) establishes procedures for the reporting and investigation of suspected child abuse. Certain types of suspected child abuse must be reported to law enforcement officials for investigation of criminal offenses. Children under the age of 18 are covered by the Act including those who receive supports and services from the mental retardation system. Providers covered within the scope of this bulletin are required to report suspected child abuse in accordance with the procedures established in the CPSL and the Protective services Regulations. The CPSL defines child abuse as any of the following when committed upon a child under 18 years of age by a parent, person responsible for a child's welfare, an individual residing in the same home as a child or a paramour of a child s parent. Any recent act or failure to act that causes non-accidental serious physical injury. Any act or failure to act that causes non-accidental serious mental injury or sexual abuse or sexual exploitation. Any recent act or series of such acts or failures to act that creates an imminent risk of serious physical injury or sexual abuse or sexual exploitation. 6

Serious physical neglect constituting prolonged or repeated lack of supervision or the failure to provide essentials of life including adequate medical care which endangers a child's life or development or impairs the child's functioning. Reports of suspected abuse are received by the Department of Human Services (DHS) ChildLine and Abuse Registry (800-932-0313), which is the central register for all investigated reports of abuse. Individuals who come into contact with children in the course of practicing their profession are required to report when they have reasonable cause to suspect on the basis of their medical, professional or other training or experience, that a child is an abused child. Every facility or agency is required by the CPSL to funnel reports to the director or a designee to be promptly reported to ChildLine. The reporting, investigation and documentation requirements of this Mental Retardation Bulletin must also be followed when a report of suspected child abuse is made. It must be noted that the definition of abuse found in the CPSL differs greatly from the definition promulgated in this bulletin. Because of this difference it is possible that an allegation may be unconfirmed in terms of the CPSL but still substantiated with reference to these guidelines. Likewise, the scope of reports subject to investigation differs so it is important to be familiar with the requirements of the CPSL. The Older Adults Protective Services Act (35 P.S. 10225.101-10225.5102) The Older Adults Protective Services Act (OAPSA) of 1987 was enacted to protect all Pennsylvanians age 60 and older. The OAPSA established a detailed system for reporting and investigating suspected abuse, neglect, exploitation, and abandonment for care-dependent individuals. Act 13 was signed into law in 1997 as an amendment to the OAPSA. Unlike the other provisions of OAPSA that applied only to adults age 60 and above, Act 13 applied to adults age 18 and above who were considered care-dependent individuals and to care-dependent individuals under age 18 if they resided in a facility serving individuals over 18. Employees or administrators of a covered entity reported suspected abuse incidents to the local Area Agency on Aging (AAA), where indicated, to the Pennsylvania Department of Aging and to local law enforcement pursuant to Chapter 7 of the OAPSA. These requirements existed in addition to the reporting procedures contained in this Bulletin. In 2002, the OAPSA was further amended by the Elder Care Payment Restitution Act. The Adult Protective Services Act of 2010 (Act 70) (Public Law 484 No. 70) In 2010, the APS Act was implemented to provide for the protection of abused, neglected, exploited or abandoned adults. The APS Act protects residents of this Commonwealth between 18 and 59 years of age who have a physical or mental impairment that substantially limits one or more major life activities. The act establishes a detailed system for reporting and investigating suspected abuse, neglect, exploitation, and abandonment for care-dependent individuals. More information and general reporting requirements for the APS Act can be found in the ODP Statement of Policy Amendments from the Reissued ODP Communication Packet 031-15, specifically the Reporting Matrix Guide (attachment #3) and the Mandatory Reporting Requirements (attachment #4). VII. Incident Management Contingency Plan In the event that a provider or county or entity is unable to report a 24-hour incident through the Home and Community Services Information System (HCSIS), faxed contingency reporting is to be utilized. 7

Incidents that are reported via fax are to be recorded on a copy of the Incident Management Contingency Form found in attachment J of the ODP Incident Management Bulletin 6000-04-01. This reporting method will satisfy regulatory requirements to report an incident in HCSIS. Additional reporting requirements must also be met for law enforcement, OAPSA, Childline and/or APS when applicable. Once complete, the Incident Management Contingency Form is to be faxed to the appropriate ODP Regional Office and to the appropriate County office. The form should have a fax cover sheet that identifies the fax as a reportable incident and states the reason that the report needed to be faxed. Faxing the Incident Management Contingency Form is a short-term solution for meeting regulatory requirement for reporting incidents; however, once access to HCSIS can be established, the incident must be entered into HCSIS. CONTACT INFORMATION: ODP Western Region Fax Number 412-565-5479 Allegheny County Fax Number 412-271-1392 Westmoreland County Fax Number 724-830-3571 If you are able to scan a document, you can e-mail the completed scanned document to yourself and then e- mail it to the appropriate ODP Regional Office and to the County DHS/OID Program using the following e-mail addresses: Dalila Bryd, ODP/Risk Management, Western Region c-dbyrd@pa.gov Michael Rudnik, Incident Mgmt Lead Michael.Rudnik@AlleghenyCounty.USmailto:Michael.Rudnik@AlleghenyCounty.US Chris Parker, Incident Mgmt Lead parkerc@westmoreland.swsix.com Lastly, you need to notify the Support Coordinator either by phone or e-mail to alert them of the incident and the reason for the need to file a contingency report. This notification is normally done when an incident is filed in HCSIS but since you are not able to file the report in HCSIS it now becomes your responsibility to make the notification. VIII. Risk Management Team A risk management review strategy describes the processes of discovery, remediation and improvement. Through data analysis, high frequency and high risk or potential problematic areas of concern requiring quality improvement can be identified and targeted for immediate remediation and improvement on a case by case basis. As part of an overall risk management review and quality improvement approach, the Risk Management Team will meet no less than monthly to conduct trend analysis of all documented incidents. Incident reports are to be reviewed to determine if agency action has been appropriate and sufficient. They are also to be reviewed in aggregate to determine if trends may be developing that may warrant further intervention. The Risk Management Team will assess the effectiveness of the incident management process and may recommend further administrative action. Administrative responses may include, but not be limited to referral to the Health Care Quality Unit (HCQU), revision of an individual plan of support, or other actions necessary to promote the health, safety and rights of individuals served. IX. Corrective Actions For each incident filed by the agency through the Home and Community Services Information System (HCSIS) there is a section to record the corrective action(s) that will be implemented as a result of the 8

incident. The corrective action section of the incident management report should contain sufficient detail to demonstrate that the action(s) taken were adequate and appropriate to protect the health, safety and rights of the individual. Corrective actions should address the actions that have taken place or will take place that will decrease the likelihood of a similar incident reoccurring. Vague and/or broad statements are not detailed enough and will initiate subsequent review which may delay closure and approval of the incident. Incident prevention and management is of the utmost importance. Following the reporting of an incident the management staff will consider all possible immediate and long-term effects to the individual, and will devise appropriate corrective action(s) to prevent future recurrences. In addition, systemic/agency wide issues which are identified through the investigative process will have timely corrective actions developed to prevent occurrences of similar types of incidents to other individuals receiving services in the agency. Documentation proving that corrective actions have been completed and implemented should be kept on file and available for review. This documentation is given to the IM representative to be secured in a locked file cabinet at the office. X. Pre-Service and Annual Training All staff shall receive training in recognizing reportable incidents and reporting responsibilities prior to working with individuals and annually thereafter. The training curriculum includes but is not limited to: Identification of abuse, neglect, rights violations and exploitation/misuse of funds Recognizing what constitutes a reportable incident Reporting incidents and reporting responsibilities Timely and appropriate actions to be taken in response to incidents Protection of health, safety and individual rights Examples and discussion of types of abuse, neglect, rights violations and exploitation/misuse of funds Prevention strategies for abuse, neglect, rights violations and exploitation/misuse of funds All certified investigators must successfully complete the 24 hour training course and pass the test as described in the ODP Incident Management Bulletin 6000-04-01 dated February 28, 2004. In addition, they must complete and pass an on-line recertification course every three years in order to maintain their certified investigator status. 9