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HSD/MAD/QAB Incident Management System. Why Report Incidents?  New Mexico State law mandates requirements for reporting alleged incidents.  Incident.

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Presentation on theme: "HSD/MAD/QAB Incident Management System. Why Report Incidents?  New Mexico State law mandates requirements for reporting alleged incidents.  Incident."— Presentation transcript:

1 HSD/MAD/QAB Incident Management System

2 Why Report Incidents?  New Mexico State law mandates requirements for reporting alleged incidents.  Incident reporting is a mechanism to ensure the health and safety of consumers receiving Medicaid services.

3 Why Report Incidents?  Incidents are reported to improve service quality by identifying issues or areas of concern.  An incident must be reported before it can be investigated.

4 INCIDENT ANAGEMENT PRINCIPLES  All adults and children receiving Home and Community Based 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  Consumers, 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.

5 New Mexico Statutes/Regulations.  In recognition of the need to report such incidents, the State of New Mexico provides statutes and individual program regulations which define the expectations and legal requirements for properly reporting consumer- involved incidents in a timely and accurate manner.

6 List of Statutes and Regulations  Adult Protective Services - NMSA 1978, Section  Department of Health NMAC  Personal Care Options NMAC B. (14), (15)  CoLTS ‘C’ Waiver NMAC E. pdfs/8_307_18_CoLTS_C_Regulations.pdf  Mi Via Waiver NMAC

7 HSD/MAD/QAB Incident Management System  This presentation and the Incident Management Guide describes the statewide reporting requirements for all incidents involving consumers served under certain Medicaid-funded, Home and Community Based service programs.  These programs include CoLTS ‘C’ Waiver, Personal Care Option Program (PCO) Mi Via.

8 What Types of Incidents Are We Required to Report? All incidents involving:  abuse,  neglect,  and exploitation,  natural or unexpected deaths,  emergency services,  law enforcement,  environmental hazards.

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 Consumer is threatened with being homeless or placed in a nursing home. Consumer is pushed or roughly handled while receiving care.

11 Abuse/Self Abuse Abuse includes self abuse Agencies may write in “self-abuse” Self abuse will be documented in the narrative section.

12 Self-Abuse Consumer is doubling up on pain medication and will not see the doctor. Consumer’s alcohol consumption results in frequent ER visits or law enforcement interventions.

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

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

15 Neglect Caregiver/family do not provide sufficient food or do not allow others to provide food. Medical appointments and treatments are routinely not attended. The home is not warm or cool enough.

16 Neglect/Self Neglect Neglect includes self neglect. Agencies may write in “self-neglect”. Self neglect will be documented in the narrative section.

17 Self Neglect Not eating enough to stay well. ◦ May be ill ◦ May believe someone is poisoning the food Refuses to bathe or change clothes. Forgets or refuses medications No heat or electricity because bills are not paid.

18 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].

19 Exploitation Caregiver uses consumer’s debit card for their own purchases People move into the home uninvited and without paying for rent or utilities Caregiver convinces consumer to sign timesheet for hours not worked

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

21 Unexpected Deaths Homicide Suicide Accident Death unlikely to be attributed to diagnosis/condition ◦ Cerebral palsy, mental health diagnosis, cognitive delay, brain injury, etc

22 Expected Deaths 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.

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

24 Emergency Services  Emergency Services refers to admission to a hospital or psychiatric facility or the provision of emergency services that results in medical care which is unanticipated and/or unscheduled for this individual and which would not routinely be provided by a community based service provider.

25 Emergency Services report this: 911 is called and the consumer refuses to be transported. The consumer gets sick at the store and the caregiver takes them to the ER. The consumer goes to the ER and then leaves after checking in but before being seen. The ER releases the consumer without providing any treatment.

26 Emergency Services DO NOT report this: The consumer is at the doctor, gets sick and the doctor sends them to the ER. The consumer 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.

27 Law Enforcement is defined as:  Law Enforcement Intervention is the arrest or detention of a person by law enforcement, involvement of law enforcement in an incident or event, or placement of a person in a correctional facility.

28 Law Enforcement Police are called to the consumers home because of a disturbance (even if the consumer is not causing the disturbance) The consumer is incarcerated. The consumer 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 consumer is creating a disturbance.

29 Law Enforcement 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 consumer 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.

30 Environmental Hazards is defined as:  An unsafe condition which creates an immediate threat to life or health.

31 Environmental Hazards 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 Frayed, broken or trailing live wires Clutter that impedes normal movement to bathrooms or exits.

32 Environmental Hazards Drugs, guns and dangerous people ◦ Blatant illegal drug use or visible evidence of the manufacture or sale of drugs ◦ Guns that are not locked up and/or are brandished by the consumer or others in the home. ◦ The consumer or others in the home threaten, frighten or harm caregivers or others providing services.

33 Submitting an Incident Report  Reporting abuse, neglect or exploitation to the MCO and HSD does not relieve a provider of mandated reporting requirements to Adult Protective Services (APS).  Incident reports must be submitted to the Consumer’s Managed Care Organization (United Healthcare or Amerigroup) and HSD/MAD/QAB within 24 hours of knowledge of the incident. Report all incidents within 24 hours! If the incident occurs on a weekend or holiday the incident must be reported on the next business day.  Description of the actual incident should always be provided by the person with the most immediate knowledge of the incident.  All incidents pertaining to the HSD programs described in this document should be reported using the Human Services Department’s Incident Report form and are submitted to HSD via FAX at ( 505)

34 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.

35 Who Completes an Incident report?  The agency is required to submit a completed report.  The person with the most immediate knowledge of the incident completes or provides the information for Section 2.  Any staff, employee or consumer may complete an incident report anonymously.

36 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.

37 APS Reporting Requirements Providers shall report to APS: Abuse, Neglect, Exploitation, And deaths suspected to be a result of ANE. Abuse, neglect, exploitation, deaths, emergency services, law enforcement involvement, and hazardous environments to: the appropriate MCO, (Amerigroup or United Healthcare) and copies to HSD/MAD/QAB (Report all incidents within 24 hours! (Next business day in the event of weekend or holiday).

38 APS REPORTING GUIDELINES  First and foremost, always ensure the safety of the consumer!  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.

39 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.

40 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.

41 Adult Protective Services Statewide Central Intake Incidents involving suspected/alleged abuse, neglect, and exploitation must be referred immediately to: Telephone: FAX:

42 Critical Incident Reporting Flow Chart

43 HSD Incident Report Form with Numbers and Instructions

44 HSD Incident Management Sample Form

45 HSD Incident Management Form

46 Where Do We FAX Incident Reports? CoLTS ‘C’ Waiver, Personal Care Option Program (PCO) Mi Via. APS Fax: CPS Fax : HSD/MAD/Quality Assurance Bureau Fax: Amerigroup Fax: United Healthcare Fax:

47 Where Do We FAX 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 CoLTS C, PCO or Mi Via the report ALSO goes to HSD/MAD/QAB Fax:

48 Fraud Alleged Fraud is reported as follows: Follow the critical incident reporting process for all cases of Abuse, Neglect and Exploitation Clearly mark as Exploitation/Alleged Fraud and fax form to You may also send an to with “Alleged Fraud” in the subject line or call

49 HSD/MAD/QAB Contact Information If you have questions about any of the forms or the content of this guide you may send a Fax to: You will receive a response to your questions within 48 hours. Please allow additional time for weekends and holidays.

50 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 consumers) 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 consultant, service coordinator or guardian 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.

51 FAQ/Best Practices What if the participant does not have a CoLTS MCO (Amerigroup or United Healthcare)? ◦ Do not send the report to a Salud MCO (Presbyterian, Lovelace, etc.) ◦ Send the report to the Consultant and APS if ANE, and other agencies as defined by the Incident Management Guide.

52 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. ◦ Anonymous reports are difficult to investigate and follow up.

53 FAQ/Best Practices I know that the state wants the person closest to the event to complete the report, but sometimes they can’t. What do I do then? ◦ Have the person complete the information for Section 2, then the agency can complete and fax the report. ◦ Call the person and get as much information as possible and complete the report. ◦ Complete the report and provide the person’s telephone number. ◦ Complete the report and state how you know what is reported. You may get a call to explain how you know what happened. If everything is on the report and it makes sense, it saves a call.

54 FAQ/Best Practices What do I do when a consumer calls in to report dangerous behavior? ◦ If a consumer 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 consumer 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 consumer should have a plan in their SSP that discusses what will occur when they share information about harm. ◦ The consultant must be immediately informed.

55 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 on if it 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 screens incident reports according to a strict criteria. An report that is screened out may be screened back in with additional information. An report that is screened out may be investigated or followed up by other parties; this is one reason reports are sent to different agencies.

56 ~End~ Questions ?

57 HSD/MAD Quality Assurance Bureau Nancy Haas, HSD/MAD/QAB Fax:


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