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Critical Incident Management System

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1 Critical Incident Management System
HSD/MAD/QB Critical Incident Management System . CENTENNIAL CARE Revised November 1, 2013

All adults and children receiving Centennial Care services should be able to enjoy a quality of life that is free of abuse, neglect, and exploitation. Staff must receive initial and ongoing training to be competent to respond to, report, and document incidents in a timely and accurate manner. Recipients, legal representatives, and guardians must be made aware of and have available incident reporting processes. Any individual who, in good faith, reports an incident or makes an allegation of abuse, neglect, or exploitation will be free from any form of retaliation. Quality starts with those who work most closely with persons receiving services.

3 HSD/MAD/QAB Incident Management System
This presentation describes the statewide reporting requirements for incidents involving Home and Community Based Services recipients enrolled in Centennial Care -the new name for New Mexico’s Medicaid Program.

4 Why Report Incidents? New Mexico State law requires reporting alleged incidents. Incident reporting is a mechanism to ensure the health and safety of recipients receiving Medicaid funding.

5 Why Report Incidents? Reporting incidents allows service delivery agencies and Managed Care Organizations (MCOs) to address concerns quickly for health and safety. Incidents are reported to improve service quality by identifying issues or areas of concern. An incident must be reported before it can be investigated.

6 New Mexico Statutes/Regulations
In recognition of the need to report such incidents, the State of New Mexico provides statutes and regulations which define the expectations and legal requirements for properly reporting recipient –involved incidents in a timely and accurate manner.

7 Statutes and Regulations
Adult Protective Services - NMSA 1978, Section 27/article-7/ Centennial Care -State of New Mexico Human Services Department Medicaid Managed Care Services Agreement Critical Incident Management. Department of Health NMAC cident_REP_INTAKE.pdf

8 What Types of Incidents Are We Required to Report?
All incidents involving: abuse neglect exploitation death-expected or unexpected emergency services L aw enforcement environmental hazards elopement and missing recipients Behavioral Health providers have an additional incident type to be discussed in later slides.

9 Abuse is defined as: Abuse means the willful infliction of injury,
unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish [ NMAC].

10 Abuse In the reporting system abuse includes:
Sexual (directed at the recipient) Physical (directed at the recipient) Verbal (directed at the recipient) Self Injury Sexual Behavior Displayed (directed at the recipient) Rape (of recipient) Sexual (recipient towards others) Physical (recipient towards others) Verbal (recipient towards others) Attempted Suicide Type not specified Not specifying the type will likely generate a call for more information.

11 Abuse Examples Recipient is threatened with being homeless or placed in a nursing home. Recipient is pushed or roughly handled while receiving care. Recipient is sexually assaulted. Recipient is made to do without food, water, or bathroom access as punishment.

12 Self-Abuse examples: Recipient is doubling up on pain medication and will not see the doctor. Recipient’s alcohol consumption results in frequent Emergency Room (ER) visits or law enforcement interventions. Recipient threatens or attempts suicide Includes cutting self, banging head repeatedly or stepping into traffic.

13 Abuse/Caregiver abuse
Caregiver abuse is important to report. Seriously impacts the delivery of services Isolates the consumer Service coordinator/consultant must be notified. Description of abuse will be documented in the narrative section of the report.

14 Caregiver abuse examples:
Sexually harasses caregivers. Threatens caregivers or their families. Consistently uses racial or ethnic slurs when talking to caregivers. Physically pushes, hits or throws things at caregivers.

15 Neglect is defined as: Neglect means the failure to provide goods
and services necessary to avoid physical harm, mental anguish, or mental illness [7.1.13 NMAC].

16 Neglect In the reporting system neglect includes:
Insufficient staffing Staff not performing assigned tasks Care not being given by family or others who have agreed to provide support Self Neglect (refuses food, hygiene, medications including substance abuse and dangerous behavior) Self Neglect (refusing services) Type not specified. Not specifying the type will likely generate a call for more information.

17 Neglect examples: Agency frequently fails to provide services that have been authorized. Staff show up but do not do assigned tasks. Family or others who have promised support do not pay the bills do not purchase sufficient food and supplies do not arrange or transport to needed medical care do not provide support as agreed in the personalized service plan for the recipient. (staying overnight, bathing after paid caregiver hours, preparing meals, etc.)

18 Self Neglect Does not eat enough to stay well.
Examples: Does not eat enough to stay well. Can no longer prepare appropriate meals. Thinks the food is being poisoned. Forgets to eat. Refuses to bathe or change clothes. Forgets or refuses medications or takes too many at a time. No heat or electricity because bills are not paid. Brandishes weapons at neighbors or caregivers. Shoplifts. Consistently refuses to allow services to be delivered.

19 Exploitation is defined as:
Misappropriation of property (i.e. exploitation) means the deliberate misplacement of consumer’s property, or wrongful, temporary or permanent use of a consumer’s belongings or money without the consumer’s consent [ NMAC].

20 Exploitation examples:
Caregiver uses recipient’s debit card for their own purchases. People move into the home uninvited and/or without paying for rent or utilities. Caregiver convinces recipient to sign timesheet for hours not worked. Recipients medications are frequently missing. Caregivers or others are taking the recipient’s property (this is exploitation even if the recipient is offering it under duress or as a result of a medical condition such as dementia). Caregiver borrows money and does or does not pay it back. Recipient is encouraged or pressured into providing sexual services with or without pay.

21 Exploitation NOTE: Incidents of exploitation may be also reports of alleged Fraud. (See slides 57-59) The Alleged Fraud field is selected if a report concerns Medicaid funding that has been paid for services not rendered (e.g. claiming time for work not completed) or for services diverted to inappropriate use(e.g. sale of Medicaid paid goods)

22 Abuse, Neglect and Exploitation (ANE)
Agencies are responsible to report immediate jeopardy incidents to Adult Protective Services (APS) immediately by phone or fax. MCOs will report all ANE incidents to APS daily. Any report made to APS must also be a report completed and submitted into the HSD website.

23 Deaths Unexpected Death: any death caused by an
accident, unknown or unanticipated cause. Natural/Expected Death: any death caused by a long-term illness, a diagnosed chronic medical condition, or other natural/expected conditions resulting in death.

24 Unexpected Deaths Examples: Homicide Suicide Accident
Death unlikely to be attributed to diagnosis/condition

25 Expected Deaths Examples: Hospice Terminal conditions
End stage renal disease Multiple strokes/heart attacks Advanced age (more than 90 years old) Deaths occurring in a facility while in treatment for disease

26 Hospice If the recipient is in Hospice care the agency will follow the hospice plan of care and will not file neglect for refusing food, medications etc. A death under the care of a Hospice agency is considered a natural/expected death.

27 Deaths Deaths are tracked by the MCOs for opportunities to improve services and outcomes of treatment. Agencies may be requested to provide additional information if needed for these reviews.

28 Deaths The criteria governing the selection of Unexpected vs. Natural/Expected Deaths is imperfect. Unexpected Deaths require investigation: Additional information may be gathered to explain the death which is added to the report. A referral to Office of Medical Investigation may be appropriate. Medical records may need to be reviewed.

29 Other Reportable Incidents (ORI) Include:
Emergency Services Law Enforcement Intervention Environmental Hazard Missing

30 Emergency Services Emergency Services refers to:
A 911 call to the home or location of the recipient (whether or not the recipient is transported) Unanticipated admission to a hospital or psychiatric facility. Emergency room visits whether taken by caregiver, family or EMT (Emergency Medical Transport)

31 Emergency Services Examples of reportable Emergency Services:
911 is called and the consumer refuses to be transported. The recipient gets sick at the store and the caregiver takes them to the ER. The recipient goes to the ER and then leaves before being seen or treated by medical staff. The ER releases the recipient without providing any treatment.

32 Emergency Services Examples of NON REPORTABLE Emergency Services:
The recipient is at the doctor, gets sick and the doctor sends them to the ER. The recipient is admitted to the hospital for a scheduled treatment or observation. An ambulance is used for transportation for either a scheduled physician visit or to the hospital for a scheduled procedure.

33 Law Enforcement Law Enforcement Intervention refers to:
the arrest or detention of a person by law enforcement involvement of law enforcement in an incident or event transportation of a person to a hospital or correctional facility.

34 Law Enforcement Examples:
Police are called to the recipient’s home because of a disturbance (even if the consumer is not causing the disturbance). The recipient is arrested and/or incarcerated. The recipient is picked up for a bench warrant or parole violation (even if they are released). The police are called to do a ‘well check’ (even if they find them ‘well’). The police are called because the recipient is creating a disturbance. A person is detained in Protective Custody. A person is transported by police to a hospital or mental health facility, voluntarily or involuntarily or through an involuntary treatment court order.

35 Law Enforcement NOTE: Law Enforcement involvement for a caregiver is NOT an a reportable incident. However, there may be a reportable incident if The caregiver has harmed or robbed the recipient. The caregiver being detained or incarcerated results in services not being delivered. The caregiver is also the natural support and is not available to provide health and safety supports.

36 Environmental Hazard Environmental hazard refers to:
An unsafe condition which has created or may create a threat to life or health or safety for the recipient or the caregiver.

37 Environmental Hazards
Examples: A fire or flood has created a hazard in the home. Animals are out of control at the home Threatening services Creating more waste that can be cleaned timely. Lack of repairs that create hazards Lack of water, electricity, heat that was in place previously Wood heat or hauled water is not considered a hazard. Holes in the floors Roofs that leak Windows and doors broken Debris not cleared. Foul smells, piles of garbage, standing dirty water, etc.. Clutter that impedes normal movement to bathrooms or exits.

38 Environmental Hazards
Examples continued: Drugs, guns and dangerous people! Blatant illegal drug use or visible evidence of the manufacture or sale of drugs. Guns that are not secured and/or are brandished by the recipient or others in the home. The recipient or others in the home threaten, frighten or harm caregivers or others providing services.

39 Environmental Hazards
The following are NOT environmental hazard incidents: The home is heated with wood (and has a functioning stove and ventilation) The home does not have running water (and the home has systems to provide safe potable water for use). Clutter is contained and does not impede function of the home or safe passage of the individual and caregiver.

40 Missing Elopement Wandering
Primarily a Behavioral Health incident type Occurs when someone is required to be somewhere and then leaves without permission or alerting others Wandering Used for those recipients who leave without intent to stay gone. May be lost or unaware of their surroundings. Not to be used for those who have intentionally left their residence without telling anyone. Those reports will be filed as “missing” without a secondary incident type.

41 Submitting an Incident Report
Incident reports must be submitted for recipients of Centennial Care through the web site for the HSD Incident Reporting System: Incidents must be reported within 24 hours of knowledge of the incident. Incidents must be reported accurately. Incidents must be reviewed by the agency and the MCO to determine if follow up is needed.

42 Submitting an Incident Report
Agencies that do not comply with incident reporting requirements are in violation of state statute and Medicaid regulations, and may be sanctioned up to and including termination of their provider agreement by an MCO or by the HSD, Medical Assistance Division.

43 Who Completes an Incident report?
The agency delivering an authorized service submits the incident report within 24 hours of knowledge of the occurrence. The MCO submits an incident within 24 hours of an occurrence discovered during MCO/recipient activities (assessment, phone call, etc.). The Financial Management Agent (FMA) submits an incident for recipients with Self Directed Services if the FMA discovers an alleged incident or receives a call from the recipient. An interested person may call or write an agency or MCO and report an incident anonymously. The agency or MCO will then submit an incident based on the information received.

44 Self Directed Services
Incident Reporting for recipients of Centennial Care Self Directed Services follows the same processes and procedures as other incident reporting. Reports will be made by the MCO Support Broker or Service Coordinator, any provider of services or by Fiscal Management Agent staff.

45 Self Directed FMA is ‘Special’
The FMA is unique when reporting incidents: The FMA does not deliver services. The FMA does not maintain a ‘primary file’. The FMA does not directly address any of the issues reported. The FMA is the only agency that ALL Self Direction recipients utilize. Maintaining accurate and complete information is a challenge. IF the FMA does not have the required information, they will state “not available to FMA” Medications, diagnoses, etc The FMA must share all the information they DO have. Name of MCO Accurate demographics SS# Address, phone, etc Date of birth Name and phone # of employee/caller

46 Behavioral Health Critical Incidents
Behavior Health Services are integrated into Centennial Care. Behavioral Health Agencies have additional functions to complete when submitting a report. Critical Incidents submitted to the database by Behavioral Health Providers include those reported by the provider and those reported to the provider by agency staff or family.

47 Behavioral Health Critical Incidents
When a Behavioral Health (BH) provider opens a report to complete, the agency’s name will self populate. The agency is recognized as a BH provider and two functions become enabled: A diagnoses dropdown box A treatment location type drop down box Also one additional incident type becomes enabled.

48 Behavioral Health Critical Incidents
Diagnoses Drop Down Only a primary diagnoses will be selected All other diagnoses relevant to the report can be added to the free text diagnoses field. Treatment Site Drop Down This is the site/service that the reporter works for at the time of the incident. The additional provider information (address, phone) will be entered in the appropriate fields.

49 Behavioral Health Critical Incidents
Many people receiving Centennial Care services have behavioral health diagnoses. Only the Behavioral Health Agencies will enter BH Critical Incidents. When other Centennial Care agencies open a report to complete, the BH functions are not available and the report can be completed as usual.

50 Behavioral Health Critical Incidents
An incident that is reported by a BH provider may be related to incidents for the same recipient submitted by other Centennial providers. These are not duplicates.

51 Reporting to Adult Protective Services
The MCOs report all incidents of Abuse, Neglect and Exploitation (ANE) which have been submitted to the HSD Critical Incident website to APS within 24 hours. If an agency directly reports a case to APS (and includes all required information) the agency will be able to get information about the report from APS. The agency is still required to report to the HSD Critical Incident Website.

52 The Adult Protective Services Act
Mandates any person having reasonable cause to believe an incapacitated adult is being abused, neglected or exploited shall immediately report that information to Adult Protective Services. If the recipient is under 18 years of age a report of Abuse, Neglect or Exploitation must be reported to Child Protective Services (CPS) Fax :

53 APS Reporting Requirements
Abuse, Neglect, Exploitation(ANE), And deaths suspected to be a result of ANE. Abuse, neglect, exploitation, deaths, emergency services, law enforcement involvement, and hazardous environments shall also be submitted to the HSD reporting website. Report all incidents within 24 hours!(Next business day in the event of weekend or holiday).

First and foremost, always ensure the safety of the recipient! The New Mexico Adult Protective Services (APS) Act mandates: Any person having reasonable cause to believe an incapacitated adult is being abused, neglected, or exploited shall immediately report that information to the department.

55 Deaths Reported to APS Deaths that are suspected of being related to abuse or neglect must be reported immediately to APS. Deaths that are the result of natural causes and/or are expected do not need to be reported to APS. If the death occurs outside of a medical facility, local law enforcement must be notified.

56 APS Procedure APS will screen all incident reports and make a determination whether investigation is warranted. If the incident involves a criminal act, local law enforcement must be notified immediately. Law enforcement must be notified by the person reporting the incident. When the incident is reported to APS, if law enforcement has not been notified APS will notify law enforcement.

57 Adult Protective Services Statewide Central Intake
Incidents involving suspected/alleged abuse, neglect, and exploitation must be referred immediately to: Telephone: FAX: (The MCO for a Centennial Care recipient will report all ANE reports to APS within 24 hours of review of the online submission) If the recipient is under 18 years of age a report of Abuse, Neglect or Exploitation must be reported to Child Protective Services (CPS) Fax :

58 HSD/MAD/Quality Bureau: Child Protective Services (CPS)
Where Do We Send Incident Reports? Centennial Care HSD/MAD/Quality Bureau: APS Fax: If the recipient is under 18 years of age a report of Abuse, Neglect or Exploitation must be reported to Child Protective Services (CPS) Fax :

59 Where Do We FAX other Incident Reports?
Other programs: DOH/DHI/IMB: (Developmental Disability Waiver & Medical Fragile) Fax: (800) DOH/DHI/HFLC: (Licensed Home Health, Assisted Living Facilities and Nursing Facilities) Fax: (888) If the Home Health patient or the Assisted Living resident is a member of Centennial Care the report ALSO goes to HSD/MAD/QB Report incidents of abuse, neglect and exploitation of any individual outside of Medicaid programs to APS as mandated by state statute

60 Alleged Fraud is reported as follows:
Follow the critical incident reporting process for all cases of Abuse, Neglect and Exploitation. Select “Alleged Fraud” check box within the form. Complete any MCO required reporting to the Managed Care Organization in which the recipient is enrolled. The MCO will review and investigate and report to the state the results of investigations.

61 Fraud Examples of Fraud
The consumer and the caregiver agree to sign off on timesheets that do not represent time worked. The caregiver has the consumer sign timesheets ahead of time and turns them in including time not worked. Billing is submitted when consumer is out of town or in the hospital. Consumer is selling Medicaid goods (Depends, DME or medications). Caregiver turns in timesheets for delivery of services to more than one consumer for the same time/date.

62 Examples of wrongdoing that are NOT fraud.
Fraud NOTE: Examples of wrongdoing that are NOT fraud. These must be reported to the HSD Critical Incident website as exploitation but do not constitute fraud; the alleged fraud field will not be selected. The caregiver takes money from the consumer’s home. The consumer uses their Social Security check for drugs or gambling. The caregiver uses the consumer’s debit card for their own purchases. Consumer is intimidated into turning over the deed to their home.

63 HSD Incident Management System FAQ/Best Practices
What about multiple reports? What about the consumer who demands that a report be created about the same thing over and over? (e.g. Accusing a previous caregiver of stealing) Develop a policy and procedure for the organization (and shared with recipients) that states multiple report requests will be reviewed and will be reported to the state on a monthly basis as one report. Make a documented call/memo to the consumer’s service coordinator and guardian (if applicable) sharing the issue and requesting assistance for the consumer to understand the purpose of incident reporting and to assist the consumer to resolve any issues in services.

64 FAQ/Best Practices What if the recipient does not have an MCO?
Select “Not Medicaid Funding” or “Fee for Service” (as appropriate) from the MCO drop down choices. For Native Americans who “OPT OUT”, use “Fee for Service” as a drop down choice. If “Not Medicaid Funding” is chosen, be prepared to answer questions from HSD. All Centennial Care recipients will select an MCO upon eligibility determination.

65 FAQ/Best Practices Can I complete a report anonymously?
If you are working for an agency, you must complete the report with your name and phone number and role with the agency. You may complete a report anonymously only if you are reporting as a private citizen who does not have a role in the services for the consumer. You may file a report based on an anonymous call. Anonymous reports are difficult to investigate and follow up and maybe screened out by the MCO and APS.

66 FAQ/Best Practices What do I do when a consumer calls in to report dangerous behavior? If a recipient calls and talks about hurting themselves or others you must have an appropriate and consistent response. Your agency must have a policy and procedure for addressing these kinds of calls. This policy must be shared with the recipient when they enroll in your agency and when you take the call about the concerning behavior. This policy will describe the options you will take which may include calling authorities or a counselor, redirecting to a crisis hot line or other interventions. The recipient should have a Care/Treatment plan that discusses what will occur when they share information about harm. The service coordinator must be immediately informed.

67 FAQ/Best Practices Why doesn’t APS put the person into a nursing home?
Why doesn’t APS ever call me back? How do I know what APS found out? APS may be able to assist a vulnerable adult to get a guardian or may be able to do an emergency support situation. They can assist the courts to determine competency. They do not make permanent decisions about people’s lives. APS can tell a reporter of an incident if the report was received. They may have information including if the call was screened in or out. And if APS needs additional information or assistance with an investigation the reporting agency may be involved. APS has very strict procedure about sharing investigations and outcomes. APS will only do this if the reporters address and phone number is clearly written on the report. APS screens incident reports according to a strict criteria. A report that is screened out may be screened back in with additional information. A report that is screened out may be investigated or followed up by other parties; this is one reason reports are sent to different agencies.

68 Managed Care Organizations
MCOs are required to review and process all critical incidents submitted to the HSD web system for their enrollees within directed timeframes, including reporting ANE to APS. MCOs are required to submit all incidents they become aware of through their activities with the recipients. MCOs are required to train all staff who work with recipients directly or indirectly on the principals and practice of reporting incidents. MCOs are accountable for reviewing and establishing procedures for follow up including working with recipients, APS, local law enforcement, tribal social services and with the agencies that provide services.

69 Managed Care Organizations
MCOs are required to ensure that agencies who subcontract to provide authorized services are reporting incidents appropriately and collaborating with follow up activities. This includes documented training and technical assistance prior to any sanctions. MCOs are required to track and trend critical incident reports and report to the state as directed. MCOs report Critical Incident data and analysis to the State monthly and quarterly. This includes reports on the total Centennial Care population, on BH critical incidents and on incidents involving recipients of Self Directed Services.

70 Behavioral Health (BH) Critical Incidents
A report is considered a “Behavioral Health Report” when submitted by a BH provider for a client enrolled in Centennial Care. A Centennial Care recipient who has a behavioral health, mental health or substance abuse diagnosis whose incident is reported by other providers is NOT considered a BH incident and the report follows the process required in this training. BH Providers must report critical incidents as directed in this training. Behavioral Health Providers have additional information they must include in the reporting system such as selecting provider type. There are incident types that are critical to BH reports. Reports to the state by the MCOs for BH incidents require BH providers to include accurate Diagnoses codes. .

71 Self Directed Services
Critical Incidents involving recipients who are receiving Centennial Care Self Directed Services are reported following the direction in this training. Reporting an incident for this population requires that the Medicaid category of eligibility (COE) be selected and also that the Self Directed program be selected. This population will be increasing dramatically with Centennial Care and MCOs are required to track incidents for this population for monthly and quarterly reporting to the state. Reports for this population will be submitted by the agency that is providing the services, the consultant or broker for the recipient and by the Financial Management Agent (FMA currently XEROX) depending on who has information regarding the incident.

Be accurate! Wrong information slows response to the issue and may violate HIPPA regulations. Have the correct information easily available to the reporter. Make sure the right people know about the incident! APS gets all Abuse, Neglect and Exploitation. These are reported by the MCO or HSD to APS from submitted reports. If you want APS to share any information with you, you must call in the report with your agency name and phone number. (See slide #38) Support Brokers and Service Coordinators need to know to help.

Be comprehensive! Make sure you have included the names and information needed to tell the story. The diary entries are available for more detailed information or updates. Be Brief! ‘Just the facts, ma’m’ (or the allegations). Opinions and information not regarding the event slow down the responsiveness. Expect the call! Make sure your agency has all the back up information and documentation of any follow up activities done by the agency. Understand your responsibilities.

74 HSD/MAD/QB Contact Information If you have questions about the website or the content of this presentation you may   You will receive a response to your questions within 48 hours. Please allow additional time for weekends and holidays.

75 ~End~ Questions ?

76 Nancy Haas, 505-476-7265 Jeanne Cournoyer, 505-827-3109
HSD/MAD Quality Bureau Nancy Haas,   Jeanne Cournoyer, Amy Salazar,

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