State f New Mexic Human Services Department Behaviral Health Prvider Critical Incident Reprting Prtcl A Cllabrative effrt f the New Mexic Human Services Department, Children Yuth and Family Department, the Centennial Care Managed Care Organizatins and the New Mexic Behaviral Health Prvider Assciatin. April 2018 April 2018 Page 0
Table f Cntents INTRODUCTION... 2 WHY... 3 WHO... 5 PROCESS... 6 WHAT... 6 WHEN... 6 WHERE & HOW... 6 TERMS AND DEFINITIONS... 8 April 2018 Page 1
INTRODUCTION This dcument is a prduct f a cllabrative effrt amng the Human Services Department (HSD), Behaviral Health Services Divisin (BHSD), the Children, Yuth and Families Department, Children s Behaviral Health Divisin, Managed Care Organizatins (MCOs), and The New Mexic Behaviral Health Prvider Assciatin. The gal in develping this dcument is t develp a ne-stp reference guide fr behaviral health prviders wh are required t reprt incidents. This dcument is t assist prviders in filing critical incidents fr thse members whse categry f eligibility falls utside f the furteen categries that are reprted n the HSD prtal. This dcument shuld be cnsidered a summary and supplement t already existing legal cntracts and regulatins. It is t be used t delineate mre clearly the fundatin f principles that have and will cntinue t infrm critical incident reprting fr recipients f behaviral health services. This dcument replaces previusly distributed, training and instructinal materials fr Behaviral Health Critical Incident Reprting. The develpment f this dcument included a review f already existing literature including but nt limited t: New Mexic Administrative Cde Incident NMAC 7.1.13 Reprting, Intake, Prcessing and Training Requirements Managed Care Plicy Manual, January 1, 2014, NMAC 8.308.2 Specialized Behaviral Health Prvider Enrllment and Reimbursement NMAC 7.20.11 Certificatin Requirements Fr Child And Adlescent Mental Health Services HSD and ther training material previusly develped and utilized. Behaviral Health Critical Incident reprting is part f ensuring that all New Mexic adults and children are receiving quality healthcare services thrugh Centennial Care and that they are free frm abuse, neglect, and explitatin. It is expected that prviders f services have a rbust quality assurance prgram that includes management f critical incidents. Ensuring quality f service is a means fr cntinued evaluatin and risk management. A reprtable Behaviral Health Critical Incident is defined as: A reprtable event is any Sentinel event defined as an unexpected ccurrence invlving death r serius physical r psychlgical injury. Serius injury specifically includes lss f limb r functin. Please see Terms and Definitins n page 8, fr clarificatin. April 2018 Page 2
WHY Critical Incident reprting is a mechanism t ensure the health and safety f State f New Mexic cnsumers wh are receiving behaviral health services thrugh cntracts with Managed Care Organizatins (MCOs), Fee fr Service prviders r with the State s Administrative Service Organizatin (ASO). Reprting facilitates a prcess f nging evaluatin t address cncerns that help imprve service quality by identifying imprtant issues. Principles and regulatin that further infrm reprting requirements: Staff must receive initial and nging training t be cmpetent t respnd t, reprt, and dcument incidents, in a timely and accurate manner. Recipients, legal representatives, and guardians must be made aware f and have available incident reprting prcesses. An incident must be reprted befre it can be investigated. New Mexic State law requires reprting alleged incidents. Adult Prtective Services (APS) NMSA 1978, Chapter 27 Public Assistance, Article 7 Adult Prtective Services, and NMAC 8.11.3, http://www.nmcpr.state.nm.us/nmac/parts/title08/08.011.0003.htm Department f Health - 7.1.13 NMAC, http://www.nmcpr.state.nm.us/nmac/parts/title07/07.001.0013.htm Human Services Department, http://www.hsd.state.nm.us/prviders/criticalincident-reprting.aspx and http://www.nmcpr.state.nm.us/nmac/parts/title08/08.308.0021.htm Children, Yuth and Families Department http://164.64.110.239/nmac/parts/title07/07.020.0011.htm Other resurces regarding requirements fr reprting incidents in New Mexic are listed belw. Be sure t check the prper regulatins, with yur MCO cntractrs, and state entities with which yu are wrking n specific r unique reprting requirements. A referral t the specific agencies may be required: Department f Health- Divisin f Health Imprvement (Develpmental Disability Waiver & Medical Fragile) DHI - DOH/DHI/IMB: Phne: 505-476-9012 Fax: 800-584-6057 https://nmhealth.rg/abut/dhi/ane/racp/ Htline t reprt abuse: 800-445-6242 Children, Yuth and Families Department (CYFD), Prgram Operatins Bureau (POB): Prviders f Residential Treatment Services, Grup Hme Services, Treatment Fster Care, Day Treatment Services, Cmprehensive Cmmunity Supprt Services, Behavir Management Services, Crisis Shelter services must cntact their LCA liaisn. https://cyfd.rg/licensing-certificatin April 2018 Page 3
Children, Yuth and Families Department (CYFD), Child Prtective Services (CPS) Statewide Central Intake (SCI) at Phne: 1-855-333-SAFE [7233] r #SAFE frm a cell phne Fax: 505-841-6691 http://cyfd.rg/cntact-us http://www.nmcpr.state.nm.us/nmac/parts/title08/08.008.0002.htm http://cyfd.rg/child-abuse-neglect/reprting-abuse-r-neglect http://cyfd.rg/behaviral-health Office f the State Auditr: Fraud, Waste, and Abuse f Public Resurces Phne: 1-866-OSA-FRAUD (1-866-672-3728) r 505-476-3800 http://www.sanm.rg/special_audits_investigatins April 2018 Page 4
WHO Any individual wh, in gd faith, reprts an incident r makes an allegatin regarding abuse, neglect, r explitatin will be free frm any frm f retaliatin. Fr any cnsumer invlved in a critical incident: 1. Fr whm the services are paid by: a. Medicaid thrugh a managed care rganizatin (MCO) including Fee fr Service BH funding, OR b. BH funding thrugh an Administrative Service Organizatin prvider (ASO), AND 2. That cnsumer is r has been receiving ne f the services belw; AND 3. Is r has been in yur care, yur agency s care, r been referred ut t anther prvider by yu in the last 30 days and is nt cnsidered discharged Yu are required t reprt the incident in the cntext f the What, When, and Hw. Services: ACT Assertive Cmmunity Treatment Acute Inpatient Hspitalizatin ARTC Accredited Residential Treatment Center BHA Behaviral Health Agency BMS Behavir Management Services CCSS Cmprehensive Cmmunity Supprt Services CMHC Cmmunity Mental Health Center CSA Cre Service Agency Detx (Excluding Medical Detx) DT - Day Treatment GH - Grup Hme IHS- Indian Health Services IOP Intensive Out-Patient MST Multi Systematic Therapy OTP- Opiid Treatment Prgram PSR Psych Scial Rehabilitatin RTC Nn-Accredited Residential Treatment Center TFC I Treatment Fster Care TFC II Treatment Fster Care TLS Transitinal Living Services Rural Health Centers Other Certified Services (specify) Other Outpatient Service (specify) April 2018 Page 5
PROCESS Prceed thrugh the next set f pages in this dcument fr clarificatin n additinal cnsideratins fr reprting including the what, when, where and hw. WHAT A reprtable Behaviral Health Critical Incident: A reprtable event is any Sentinel event defined as an unexpected ccurrence invlving death r serius physical r psychlgical injury. Serius injury specifically includes lss f limb r functin. WHEN A behaviral health prvider/agency delivering an authrized service must submit incident reprts within 24 hurs f knwledge f the ccurrence r in the event that an incident ccurs n a weekend r hliday, reprt the incident next business day, NMAC 7.1.13.7 t the apprpriate State designatins and/r MCOs. Other reprting requirements may be applicable with respect t APS, CPS, LCA, r prfessinal licensing bards. Be familiar with thse if yu are wrking with children r adults that fall under special prtectins. WHERE & HOW This dcument is t assist prviders in filing critical incidents fr thse members whse categry f eligibility falls utside f these furteen categries that are reprted n the HSD Critical- Incident-Prtal. Fr apprval t access the HSD Critical Incident Prtal email: HSD-QB-CIR@state.nm.us fr credentials. The HSD Critical-Incident-Prtal is lcated at: https://criticalincident.hsd.state.nm.us The prcess fr submitting reprts include fax and/r secure email fr all Categries f Eligibility (COEs) utside f these 14. When filing with each MCO please refer t the fllwing infrmatin: The fllwing categries f eligibility are reprtable via the HSD prtal: 100 with NFLOC 200 with NFLOC COE 81 COE 83 COE 84 COE 90 COE 91 COE 92 COE 93 COE 94 COE 95 * COE 001 COE 003 COE 004 April 2018 Page 6
* Althugh COE 095 is listed n the HSD CIR Prtal as being reprtable thrugh that website, the crrect methd fr reprting CIRs assciated with COE 095 is t reprt t the NM Department f Health (DOH) Incident Management Bureau (cntact infrmatin listed belw). The categries f eligibility 095 (Medically Fragile Waiver) r 096 (Develpmental Disability Waiver) shuld be reprted t: NM Department f Health (DOH) Incident Management Bureau: Phne: (800) 445-6242 Fax: 505-584-6057 If nt using the HSD Critical Incident Prtal, the written frm can be submitted via belw: Centennial Care Medicaid with MCO: Blue Crss Blue Shield (BCBSNM) Phne: 855-699-0042, Fax: 505-816-5831 Email: HCSC_BCBS_SPHI@bcbstx.cm Mlina Fax: 855-260-8737 Email: MlinaNewMexicCIR@Mlinahealthcare.cm United Health Care (UHC) Fax: 866-751-2449 Email: qm-nm@uhc.cm Presbyterian Fax: 505-213-0686 Email: Criticalincident@phs.rg Human Services Department/ Medical Assistance Divisin: - Fee-Fr-Service, Fax: 505-827-3126 Children Yuth and Family Department/ Prgram Operatins Bureau: Fr a service licensed r certified by CYFD/POB fax reprt t 505-827-4595 All CIRs sent n behalf f nn-medicaid clients shuld be reprted t BHSD via fax t: 505-476-9272. The CIR Frm and CIR Prtcl can be fund n the HSD website: http://www.hsd.state.nm.us/prviders/critical-incident-reprting.aspx If there are questins abut critical incident reprting fr BHSD clients, send these t: bh.qualityteam@state.nm.us If there are questins abut critical incident reprting r COEs fr Medicaid clients, send these t: HSD-QB-CIR@state.nm.us April 2018 Page 7
TERMS AND DEFINITIONS f SENTINEL EVENTS Sentinel Events are drawn frm the Jint Cmmissin standards are bradly defined as an ccurrence invlving death r serius physical r psychlgical injury, r the risk theref. The sentinel events listed belw appear n the Critical Incident Reprting frm-appendix A and shuld be reprted t BHSD. Severe Harm Permanent harm Severe temprary harm Severe temprary harm is critical, ptentially life-threatening harm lasting fr a limited time with n permanent residual, but requires transfer t a higher level f care/mnitring fr a prlnged perid f time, transfer t a higher level f care fr a life-threatening cnditin, r additinal majr surgery, prcedure, r treatment t reslve the cnditin. Cnsumer twards ther, nt invlving law enfrcement. Missing recipients Abductin Abductin f any individual served receiving care, treatment, r services. Elpement Any elpement (that is, unauthrized departure) f a cnsumer frm a staffed arund-the-clck care setting (including the ED) leading t the death, permanent harm r severe temprary harm f the individual served. Sexual Incidents Sexual abuse/assault (including rape) as a sentinel event is defined as nncnsensual sexual cntact invlving a cnsumer and anther cnsumer, staff member, r ther perpetratr while being treated r n the premises f the rganizatin, including ral, vaginal, r anal penetratin r fndling f the cnsumer s sex rgan(s) by anther individual s hand, sex rgan, r bject. One r mre f the fllwing must be present t determine that it is a sentinel event: Any staff-witnessed sexual cntact as described abve Admissin by the perpetratr that sexual cntact, as described abve, ccurred n the premises Sufficient clinical evidence btained by the rganizatin t supprt allegatins f uncnsented sexual cntact. Rape, assault (leading t death, permanent harm, r severe temprary harm), r hmicide f any individual served receiving care, treatment, r services while receiving services at the rganizatin Rape, assault (leading t death, permanent harm, r severe temprary harm), r hmicide f a staff member, licensed independent practitiner, visitr, r vendr while n site at the rganizatin. Flame r unanticipated smke, heat, r flashes ccurring during an episde f patient care. Unsafe cnditin which creates, r may create, a threat t the life, health, r safety f the recipient. April 2018 Page 8
Death Unknwn- requiring fllw up with Office f Medical Examiner Suicide f any individual served currently receiving care, treatment, r services at an agency r prvider r within 72 hurs f discharge, including frm an rganizatin s emergency department (ED). Medicatin/treatment errr(s) Under r verdse r medicatin errrs requiring treatment. Natural causes Accident Secndary t use f restraints Including restraints, seclusin, and therapeutic hlds. Member death by hmicide April 2018 Page 9