1. Critical Incident Reporting System (CIRS)
Linda Metzger
Colorado Department of Health Care, Policy & Financing

2. What Is a Critical Incident?
Any actual or alleged event or situation that creates a significant risk of substantial or serious harm to the health or welfare of a client.
Could have or had a negative impact on the mental and/or physical well being of a client in the short or long term.

3. Applicable Waiver Programs
Persons with Brain Injury (BI)
Persons with Mental Illness (MI)
Persons Living with AIDS (PLWA)
Elderly, Blind & Disabled (EBD)
Persons with Spinal Cord Injury (SCI)
Children with Life Limiting Illness (CLLI)
Children’s HCBS (CHCBS)
Children with Autism (CWA)
The Department’s BUS CIRS has been established to report and track critical incident information involving Medicaid clients enrolled in these HCBS waiver programs.

4. Why does the State need to track Critical Incidents?
To assure that necessary safeguards have been taken to protect the health and welfare of the individuals receiving 1915c waiver services
To identify, address and seek to prevent the occurrence of abuse, neglect and exploitation on a continuous basis
To comply with key regulatory requirements from CMS regarding monitoring
To insure remediation (follow up) actions are initiated when appropriate
Centers for Medicare & Medicaid Services (CMS) Requires:
42 CFR –
You signed a provider agreement with Federal Medicaid and thereby must abide by federal requirements to serve HCBS waiver clients. CMS requires the reporting of critical incidents to protect and monitor the health and welfare of Medicaid waiver clients. These are fragile clients that would be in nursing facilities if they were not monitored closely in the community.If we don’t report critical incident data to CMS, they could pull certain HCBS provider services. We don’t want service options to be eliminated.

5. Critical Incidents and the Department’s Quality Improvement Strategy
Monitoring Critical Incidents is a part of the Department’s Global Quality Improvement Strategy encompassing three functions:
Discovery
Remediation (Follow-Up)
Continuous Improvement
Discovery: Collecting data in order to assess services, delivery, programs, and providers to identify areas for improvement.
Remediation: Taking action to remedy specific problems or concerns that arise to secure a client’s immediate health and welfare.
Continuous Improvement: Utilizing data and quality information to initiate actions that lead to continuous improvement in the HCBS Waiver program.

6. Providers of Waiver Services
Waiver services are furnished at widely dispersed sites throughout the community
Typically include: large and small private-sector provider organizations, assisted living facilities, adult day care facilities, case managers, individual personal assistants and attendants, clinicians, neighbors and other community members who support individuals
HCBS waiver service delivery networks are complex.
Maintaining and improving quality in diverse service delivery environments while maintaining flexibility is a challenge.

7. Number of Critical Incidents Reported per Month
There was a significant increase in reporting over the past 3 years.
/month
/month
Jan.-June /month
July-Dec /month
Jan.- July /month
This increase in CIRs reporting may be due to:
1.some significant changes were made to improve the entry process, data definitions, data consistency, and reporting capabilities in CIRS.
2.Resolution of BUS programming issues
3.Clearer CI definition
4. My presence and more intense education and support.
5. HCPF Reviews

8. Reporting Issues
Some providers are very diligent about reporting critical incidents to SEP/CMAs
Some agencies understand the CIR reporting process and expectations well and others do not
Some agencies are over-reporting incidents, e.g. reporting unnecessary events
Some SEP/CMA regions have a high frequency of critical incidents while others have a low frequency
These finds may also be an indication of the need for additional training
Clarification of the reporting requirement
Improvement of the CIRS reporting system

9. Timely Reporting Requirements
HCBS Waiver Service Provider Case Manager
( within 24 hours or one business day)
Case Manager HCPF (BUS)
Follow-up and investigation
Case Manager responsibility?
Provider responsibility?
Other entity Responsibility?
All HCBS Waiver service providers are required to report critical incidents to their area SEP within 1 business day of learning of the incident.
SEPs are required to report all critical incidents they learn of from providers, directly or indirectly, to the Department via the BUS within 1 business day of learning of an incident via the CIRS.

10. Provider Reporting Forms
Provider Services>provider services>forms>Critical Incident reporting systems forms
1.HCBS Provider Critical Incident Information Form
2. Provider Critical Incident Follow-Up Form

11. Types of Critical Incidents to Report
Death
Suspected Abuse/Neglect/Exploitation
Serious Illness
Injury to Client
Damage to Client’s Property or Theft
Medication Management
Other High Risk Issues

12. Death Types Ongoing Medical Condition/Illness/Disease
New Medical Condition/Illness
Unexpected/Unknown Cause
Completed Suicide
Homicide
Accidental Death
Other
All Occurrences of death should be reported.
If the person has been in ailing health, do not make the assumption that the ailment was the cause of death unless there is reasonable certainty the cause of death was an expected outcome of the client’s ongoing illness.

13. Suspected Abuse, Neglect or Exploitation
Abuse includes actions which result in bodily harm, pain or mental distress.
Neglect is a failure to provide care and service when a waiver client is unable to care for him or herself.
Exploitation is the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a client’s belongings or money without the client’s consent.

14. Serious Illness/Medical Crisis
Infection (UTI)
Dehydration
Cancer
Diabetic Crisis
Mental Illness symptoms
Medical crisis
Other illness
Recurring Illness
Heart attack (MI)
Stroke (CVA)
Pneumonia
Respiratory failure
Seizure
illness requiring treatment beyond first aid includes:

15. Cause of Serious Illness
New medical condition
Existing medical condition
Treatment error
Medication
Poor care
Undetermined
Other

16. Serious Injury Fracture/Dislocation
Laceration
Serious Burn
Head Injury
Multiple injuries
Unknown injury from fall requiring medical attention
Unknown injury
Other injury

17. Cause of Serious Injury
Fall
Accident
Seizure
Assault
Choking/Aspiration
Physical Restraint
Undetermined
Other

18. Damage to Client’s Property/Theft
Deliberate damage, destruction, theft, misplacement or use of a client’s belongings or money without the client’s consent, including the deliberate diversion of medications
Need to know the person involved and if damage or theft

19. Medication Management
Problems with medication dosage, scheduling, timing, set-up, compliance, administration or monitoring which can result in documented harm or an adverse effect which necessitates medical care.
Event Type
Cause for event
Administered by
Event type is wrong meds, meds omission, wrong dose, overdose etc
Cause forgotten, refusal ad min error

20. Other High Risk Issues
Serious issues that do not yet rise to the level of a critical incident, but have the potential to do so in the future, including such events such as environmental hazards, suicide threats, self-injurious behaviors, arrest or detention, etc.
This type of critical incident always requires
follow-up.

21. Types of High Risk Issues
Lost/missing person
Loss of Home/Eviction
Client fraud
Provider fraud
Serious criminal offense
(offense by client)
Client abuse toward others
Unusual aggressive behavior
Suicide ideation
Suicide attempt
Substance abuse
Media involvement
Environmental hazard
Restraints used
In the review of CIRS reports, numerous reports were deemed either unnecessary or inappropriate

22. Common Reporting Items
1. Hospitalizations 2. ER Visits 3. Dr. Visits 4. Law Enforcement Involvement

23. Unnecessary or Inappropriate Reporting Examples
Lifeline Activation not related to a specific incident type
Reports about non-HCBS persons
Due to weakness in his legs, client fell in the dining room, no ER visit
Client said she tripped over her dog and fell again
Client complained of having severe neck pain
Client was scratched on left forearm by dog paw

24. Recording a Critical Incident Report
When reporting a critical incident, be prepared to provide enough information so the reviewer knows:
Who was involved in the incident
What were the circumstances of the incident - details
Where the incident happened
When the incident took place, Date & Time
Provide enough detailed information to substantiate the critical nature of the incident and the follow-up actions taken and/or referrals made to remedy the situation and ensure the health and welfare of the client.

25. Mandatory Reporting Responsibilities
Reporting Critical Incidents in the BUS does not relieve the provider, provider agency or SEP/CMA of other forms of mandated reporting, including reports to law enforcement, Child or Adult Protective Services, or Occurrence Reports to the Colorado Department of Public Health and Environment
Never assume someone else, including the Department, will make or has made the mandated reports on your behalf.

26. After a Critical Incident is Reported
HCPF Waiver Program Staff will review CIRS reports on daily basis checking for completeness of reports to determine if the report:
Provides enough detail to understand the circumstances of the incident
Documents the steps taken to respond to incident
Identifies how client’s safety has been addressed and the follow-up measures taken and/or planned
Documents whether mandatory reporting has occurred

27. After a Critical Incident is Reported
There will be instances when additional follow-up by the SEP/CMA will be required:
when reports lack sufficient information for the reviewer to understand the nature of the incident
how a client or situation has been stabilized
what safety measures have been taken to investigate and remedy the circumstances
The Department will provide feedback to the SEP/CMA when reports are found to be unnecessary due to the nature of the incident.

28. Entering a CIR in the BUS
After you login to the BUS, identify the client for report entry

29. CIRS – Entering a Critical Incident
After you verified you have the correct client, click on “Critical Incident Reports”

30. CIRS – Entering a CIR
You can click on “Add New CIRS” or “Add Critical Incident” to start the entry process

31. CIRS – Entering the incident info
Make sure all elements are completed

32. CIRS – Incident Specific Descriptors
Definition of what types of events are appropriate for each incident type
Complete a thorough description of the incident circumstances
Complete the incident specific descriptors

33. CIRS – Persons Involved
After completing the incident descriptors, click “Persons Involved”
Complete the sections for name, relationship to client, and role
Click “Add” to enter additional persons involved

34. CIR – Mandatory Reports Made
After completing Persons Involved, click on Mandatory Reporting Steps
Make sure all sections are complete
Click “Add” to enter additional mandatory reports made

35. CIRS – Follow Up Actions
After completing Mandatory Reporting Steps, click on Follow-up Actions Taken
Make sure follow-up actions are complete. This section describes the actions take to remedy the situation and/or secure the client’s health and welfare
Click “Add” to enter additional follow up actions

36. After Follow-up Actions, click on Referrals Made
CIRS – Referrals Made
After Follow-up Actions, click on Referrals Made
Complete a referral screen for each referral completed in relationship to the incident that occurred. Please be descriptive of actions take and reason for referral

37. CIRS – Persons Notified
After completing Referral Steps, click on Persons Notified
Complete all sections of the person notified
Click “Add” to enter additional persons notified

38. CIRS – Post Report Follow-up
Select Post Report Follow-up to document additional incident related information
Provide narrative description of additional information

39. HCBS Provider Reports to SEP/CMA
The Department does not require any specific method of communication between HCBS Provider Agencies and SEP/CMAs
A form entitled “PROVIDER CRITICAL INCIDENT REPORTING FORM” has been provided as a means of capturing the detail necessary for reporting incidents; but, it is not a required by the Department.
It is important for the SEP/CMA agency to make certain the Provider and/or Provider Agency are providing them with sufficient detail to complete the CIR in the BUS.
Having enough incident detail from the provider will make the reporting process more efficient and minimize the need to seek additional follow-up information from the provider.

40. QUESTIONS???