Critical Incidents Service Provider Requirements Guide This guide should be reviewed together with the Critical Incidents Policy, Critical Incident Report, and Appendix One of the policy which lists the 25 critical incident types. Purpose of Reporting a Critical Incident Critical incident reporting is an important formal safeguard designed to protect the well-being and rights of individuals accessing CLBC funded services. Critical incidents must be reviewed and responded to in a timely manner by service providers, CLBC, and Community Care Facilities Licensing (CCFL). Service providers must follow up on and review critical incidents for the purpose of prevention, continuously improving the quality of services, and effectively responding to the needs of individuals served. Service providers are required to review and analyze all critical, serious, and/or unusual incidents at least once per year to consider: critical incident causes and trends actions that will be taken to avoid future incidents the results of efforts to avoid similar incidents from the previous review period, including any relevant education or training that was completed by those involved Reporting must comply with CLBC s contractual requirements and CCFL. What is a Critical Incident? A critical incident is a serious or unusual event that involves an individual accessing CLBC funded services and occurs while they are receiving services. A list of critical incidents is included in Appendix One of CLBC s Critical Incidents Policy. Reporting Critical Incidents Service providers have different reporting requirements depending on whether they have a licensed facility or they have an unlicensed program. Licensed Facilities As required under Community Care Facilities Licensing, a licensed facility must: Inform the Regional Healthy Authority s Medical Health Officer of reportable incidents that involve an individual accessing CLBC-funded services March 2016 Critical Incidents: Service Provider Requirements Guide 1
Submit a completed Community Care Facilities Licensing Incident Form to the Medical Health Officer AND submit the Funded Agency copy of the same form to the local CLBC office The list of reportable incidents and definitions can be found on the back of the CCFL Incident Form. Any incident that is reported to CCFL must also be reported to CLBC. It is important to note that there are 6 additional critical incident types that must be reported by licensed facilities to CLBC. These are not included on the CCFL Incident Form and must be reported using CLBC s Critical Incident Report. Service Providers can learn more about CCFL reporting requirements and obtain copies of incident forms from the local CCFL Office. Unlicensed Programs CLBC requires unlicensed programs to report critical incidents by submitting the Critical Incident Report to the local CLBC office. Service providers can get copies of the Critical Incident Report from the SERVICE PROVIDER section of CLBC s website or the local CLBC office. Reporting Incidents of an Urgent Nature when CLBC Offices are Closed When CLBC offices are closed, service providers must contact the Ministry of Children and Family Development (MCFD) After Hours Office @ 310-1234 (no area code needed) to report critical incidents of an urgent nature. The MCFD After Hours Office is a reporting line intended to support the immediate safety and well-being of individuals until CLBC offices reopen. Service providers should provide MCFD After Hours with the following information when reporting an urgent critical incident: Individual s name and date of birth Service provider contact information and an alternate contact An explanation of the incident When MCFD After Hours receives a report, they may contact a CLBC manager. March 2016 Critical Incidents: Service Provider Requirements Guide 2
Completing the Critical Incident Report The list of critical incident types can be found on the back of the Critical Incident Report and in Appendix One of CLBC s Critical Incidents Policy. After a critical incident occurs, the service provider must complete a Critical Incident Report using the guidelines below. Guidelines for Submitting Critical Incident Reports to CLBC For incidents of an urgent nature (e.g. any allegation of abuse or neglect, unexpected death, attempted suicide), service providers must immediately call their CLBC liaison analyst (or the MCFD After Hours Office when CLBC offices are closed). If the liaison analyst is unavailable, service providers are to contact the local CLBC office and will be directed to another analyst. Once contact has been made, the service provider must fax the completed report either a copy of CLBC s Critical Incident Report or the Community Care Facilities Licensing Incident Form within 24 hours to the local CLBC office. For incidents that are not of an urgent nature (e.g. unexpected illness, aggressive / unusual behaviour), service providers must mail or fax the completed Critical Incident Report - or the funded agency copy of the Community Care Facilities Licensing Incident Form within 5 business days to the local CLBC office. CLBC will accept the following forms: CLBC s Critical Incident Report Community Care Facilities Licensing Incident Form Critical incident reports produced from a service provider s information management system (e.g. Sharevision, NucleusLabs) that contain information identical to CLBC s Critical Incident Report Allegations of Abuse / Neglect Service providers must immediately report allegations of abuse or neglect. Immediate notification is required regardless of whether or not the service provider has completed an internal investigation. Why can service providers only submit critical incident reports by mail or fax? Service providers may only submit Critical Incident Reports to CLBC either by mail or fax to ensure the security of the information being provided. CLBC is unable to accept CIRs submitted by email due to security concerns. March 2016 Critical Incidents: Service Provider Requirements Guide 3
Guidance to Completing the Critical Incident Report 1. Name of Program / Place of Service Print the name of the program or place of service (reference the relevant CLBC contract to ensure accuracy of reporting). 2. Phone Number Print the service provider s phone number. 3. Address Print the street address and city of where the home is located or the program is delivered. 4. Name of Service Provider Print the name of the service provider (reference the relevant CLBC contract to ensure accuracy of reporting). 5. Service Category Identify the type of service being delivered when the incident occurred (reference the relevant CLBC contract to ensure accuracy of reporting e.g. community inclusion, residential, respite). 6. Licensed / Not licensed Indicate if the incident occurred at a licensed facility or within an unlicensed program. 7. Person (s) Involved Print the name of the individual(s) involved, including their date of birth and gender. Check all relevant boxes (e.g. individual served, visitor, other) to identify those involved in the incident or who may have information of the incident. o If Other is checked, print the person s name (s) List all person(s) adversely affected by the incident (e.g. staff, other individuals served). 8. Type of Incident Reportable to CLBC 9. Details of the Incident What Occurred Check the critical incident type that best reflects the incident being reported (choose ONE ONLY). Refer to the list of critical incident types on the back of the Critical Incident Report to ensure the appropriate incident type is reported. For further information, refer to Appendix One of CLBC s Critical Incidents Policy. It has additional information not found on the report for several critical incident types. Contact your CLBC liaison analyst if you have any questions. When describing the incident, identify: When and where the incident occurred (date, time, and location of incident). Be as specific as possible. What happened - provide details about the negative impact of the incident on the individual served. How the incident occurred. Identify any physical or March 2016 Critical Incidents: Service Provider Requirements Guide 4
environmental factors (e.g. slippery floors, medications) that may have contributed to the incident and note whether the incident was witnessed (e.g. by staff or other individuals). What immediate action (s) was taken (e.g. first aid) by service provider staff to address or resolve the incident. In case of a death, whether it was an expected or unexpected death (e.g. note if there were any previous indications that death may be imminent). NOTE: Unlike CCFL, CLBC requires a service provider to report an individual s death even if they die while in hospital. 10. Details of the Incident Actions Taken Identify: The actions taken to address or resolve the incident. Any measures taken to prevent a similar incident from occurring again. Any recommendations that have been or will be implemented (e.g. updating the individual s Behaviour Support and Safety Plan, supporting the individual to find a new home or different program). 11. Notification Check all appropriate boxes of individuals / agencies notified about the incident. Include specific names if possible. Print the name, contact information, and identify the nature of the individual s relationship to the family member / representative who was notified. Provide the date and time for each notification. 12. Signatures Print the name, position, signature, and date and time for the following people: o person who completed the form o the supervisor or manager o the witness or attending staff Non-Reportable Incidents Service providers are required to maintain a record of all unexpected or unusual incidents (in addition to critical incidents reported to CLBC) for internal purposes. A CLBC liaison analyst will periodically review records of non-reportable incidents with service providers as part of ongoing monitoring of services and programs. These records should not be sent to CLBC but should be available for review on request. March 2016 Critical Incidents: Service Provider Requirements Guide 5
Follow-Up Actions As part of the critical incident process, service providers may be contacted by an analyst. CLBC staff are required to follow up on certain critical incident types and will use their discretion about whether or not to follow-up on other types. Incident types that require analyst follow-up are identified in Appendix One of the Critical Incidents Policy. CLBC follow up may include visiting the service provider (i.e. program, activity, or home) and interviewing the individual, staff, and others involved. If necessary, analysts may coordinate investigations with agencies that have regulatory and investigative mandates such as CCFL and the local police. If a follow-up plan has been developed, service providers must inform CLBC on the status of the recommendations that have been or will be implemented so that they can be captured on the individual s file. Review of Critical Incidents Service providers are expected to complete their own incident trend analysis at least once per year as part of ongoing continuous quality improvement efforts. CLBC analysts may ask to review incident reports as part of routine monitoring activities. Questions If you have questions about critical incident reporting, please contact your liaison analyst. March 2016 Critical Incidents: Service Provider Requirements Guide 6