Presentation on theme: "Critical Incident Reporting System (CIRS)"— Presentation transcript:
1Critical Incident Reporting System (CIRS) Linda MetzgerColorado Department of Health Care, Policy & Financing
2What 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.
3Applicable 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.
4Why 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 servicesTo identify, address and seek to prevent the occurrence of abuse, neglect and exploitation on a continuous basisTo comply with key regulatory requirements from CMS regarding monitoringTo insure remediation (follow up) actions are initiated when appropriateCenters 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.
5Critical 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:DiscoveryRemediation (Follow-Up)Continuous ImprovementDiscovery: 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.
6Providers of Waiver Services Waiver services are furnished at widely dispersed sites throughout the communityTypically 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 individualsHCBS waiver service delivery networks are complex.Maintaining and improving quality in diverse service delivery environments while maintaining flexibility is a challenge.
7Number of Critical Incidents Reported per Month There was a significant increase in reporting over the past 3 years./month/monthJan.-June /monthJuly-Dec /monthJan.- July /monthThis 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 issues3.Clearer CI definition4. My presence and more intense education and support.5. HCPF Reviews
8Reporting IssuesSome providers are very diligent about reporting critical incidents to SEP/CMAsSome agencies understand the CIR reporting process and expectations well and others do notSome agencies are over-reporting incidents, e.g. reporting unnecessary eventsSome SEP/CMA regions have a high frequency of critical incidents while others have a low frequencyThese finds may also be an indication of the need for additional trainingClarification of the reporting requirementImprovement of the CIRS reporting system
9Timely Reporting Requirements HCBS Waiver Service Provider Case Manager( within 24 hours or one business day)Case Manager HCPF (BUS)Follow-up and investigationCase 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.
10Provider Reporting Forms Provider Services>provider services>forms>Critical Incident reporting systems forms1.HCBS Provider Critical Incident Information Form2. Provider Critical Incident Follow-Up Form
11Types of Critical Incidents to Report DeathSuspected Abuse/Neglect/ExploitationSerious IllnessInjury to ClientDamage to Client’s Property or TheftMedication ManagementOther High Risk Issues
12Death Types Ongoing Medical Condition/Illness/Disease New Medical Condition/IllnessUnexpected/Unknown CauseCompleted SuicideHomicideAccidental DeathOtherAll 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.
13Suspected 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.
15Cause of Serious Illness New medical conditionExisting medical conditionTreatment errorMedicationPoor careUndeterminedOther
16Serious Injury Fracture/Dislocation LacerationSerious BurnHead InjuryMultiple injuriesUnknown injury from fall requiring medical attentionUnknown injuryOther injury
17Cause of Serious Injury FallAccidentSeizureAssaultChoking/AspirationPhysical RestraintUndeterminedOther
18Damage 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 medicationsNeed to know the person involved and if damage or theft
19Medication 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 TypeCause for eventAdministered byEvent type is wrong meds, meds omission, wrong dose, overdose etcCause forgotten, refusal ad min error
20Other High Risk IssuesSerious 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 requiresfollow-up.
21Types of High Risk Issues Lost/missing personLoss of Home/EvictionClient fraudProvider fraudSerious criminal offense(offense by client)Client abuse toward othersUnusual aggressive behaviorSuicide ideationSuicide attemptSubstance abuseMedia involvementEnvironmental hazardRestraints usedIn the review of CIRS reports, numerous reports were deemed either unnecessary or inappropriate
22Common Reporting Items 1. Hospitalizations 2. ER Visits 3. Dr. Visits 4. Law Enforcement Involvement
23Unnecessary or Inappropriate Reporting Examples Lifeline Activation not related to a specific incident typeReports about non-HCBS personsDue to weakness in his legs, client fell in the dining room, no ER visitClient said she tripped over her dog and fell againClient complained of having severe neck painClient was scratched on left forearm by dog paw
24Recording a Critical Incident Report When reporting a critical incident, be prepared to provide enough information so the reviewer knows:Who was involved in the incidentWhat were the circumstances of the incident - detailsWhere the incident happenedWhen the incident took place, Date & TimeProvide 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.
25Mandatory 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 EnvironmentNever assume someone else, including the Department, will make or has made the mandated reports on your behalf.
26After 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 incidentDocuments the steps taken to respond to incidentIdentifies how client’s safety has been addressed and the follow-up measures taken and/or plannedDocuments whether mandatory reporting has occurred
27After 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 incidenthow a client or situation has been stabilizedwhat safety measures have been taken to investigate and remedy the circumstancesThe Department will provide feedback to the SEP/CMA when reports are found to be unnecessary due to the nature of the incident.
28Entering a CIR in the BUS After you login to the BUS, identify the client for report entry
29CIRS – Entering a Critical Incident After you verified you have the correct client, click on “Critical Incident Reports”
30CIRS – Entering a CIRYou can click on “Add New CIRS” or “Add Critical Incident” to start the entry process
31CIRS – Entering the incident info Make sure all elements are completed
32CIRS – Incident Specific Descriptors Definition of what types of events are appropriate for each incident typeComplete a thorough description of the incident circumstancesComplete the incident specific descriptors
33CIRS – Persons Involved After completing the incident descriptors, click “Persons Involved”Complete the sections for name, relationship to client, and roleClick “Add” to enter additional persons involved
34CIR – Mandatory Reports Made After completing Persons Involved, click on Mandatory Reporting StepsMake sure all sections are completeClick “Add” to enter additional mandatory reports made
35CIRS – Follow Up Actions After completing Mandatory Reporting Steps, click on Follow-up Actions TakenMake sure follow-up actions are complete. This section describes the actions take to remedy the situation and/or secure the client’s health and welfareClick “Add” to enter additional follow up actions
36After Follow-up Actions, click on Referrals Made CIRS – Referrals MadeAfter Follow-up Actions, click on Referrals MadeComplete a referral screen for each referral completed in relationship to the incident that occurred. Please be descriptive of actions take and reason for referral
37CIRS – Persons Notified After completing Referral Steps, click on Persons NotifiedComplete all sections of the person notifiedClick “Add” to enter additional persons notified
38CIRS – Post Report Follow-up Select Post Report Follow-up to document additional incident related informationProvide narrative description of additional information
39HCBS Provider Reports to SEP/CMA The Department does not require any specific method of communication between HCBS Provider Agencies and SEP/CMAsA 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.