1. Critical Incident Reporting System (CIRS)
Changes, Improvements & Expectations
Bill Brewer
Health Outcomes & Quality Management Section
Colorado Department of Health Care, Policy & Financing

2. CIRS Applicable Waiver Programs
Children’s HCBS
Children with Autism Persons with Brain Injury
Persons with Mental Illness
Persons Living with AIDS
Elderly, Blind & Disabled
Hospice Waiver
DD Waivers report Critical Incidents to the Division of Developmental Disabilities via their web-based reporting system

3. 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 has had, a negative impact on the mental and/or physical well being of a consumer in the short or long term.

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 recipients of services
To identify, address and seek to prevent the occurrence of abuse, neglect and exploitation on a continuous basis
Centers for Medicare & Medicaid Services (CMS) Requires:
42 CFR –

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
Continuous Improvement
Discovery: Collecting data in order to assess the service delivery of the program, identifying both strengths and opportunities for improvement.
Remediation: Taking action to remedy specific problems or concerns that arise.
Continuous Improvement: Utilizing data and quality information to engage in actions that lead to continuous improvement in the HCBS Waiver program.

6. The Challenge of Maintaining Quality In Waiver Services
Waiver services are furnished at widely dispersed sites throughout the community
Typically include: large and small private-sector provider organizations, 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 challenging.

7. What drove the changes and improvements to the existing CIRS?
There was significant variation in the reporting patterns of SEP/CMAs over a 10 month period:
2 SEP/CMAs made ZERO reports
2 SEP/CMAs reported over 200 incidents each
AVERAGE number of reports made was 60
12 SEP/CMAs recorded 89% of all Incidents
After reviewing the data collected from the existing CIRS during a 10 month period, it was determined some significant changes were needed to improve the entry process, data definitions, data consistency, and reporting capabilities.

8. What do these findings suggest?
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 findings may also be an indication of the need for additional training
Clarification of the reporting requirement
Improvement of the CIRS reporting system

9. What has been Changed and Improved?
Different Incident Types – reduced from 9 to 6 types
Addition of reporting provider identification
Limiting Entry to Only 1 Incident Type per entry
Addition of more specific incident descriptors
Limiting waiver program areas
Capturing the provider info is an important addition which will help the Department identify patterns and trends occurring with providers
Limiting the entry of only 1 incident type will help the department examine incident trends in a more focused manner

10. What has been Changed and Improved?
Improvements have included:
Increased efficiency of recording process
Establishment of Follow-up Procedures
Refinement of data elements for more objective data
Establishment of periodic reports and analysis
Clarification of expectations for Waiver Program Staff, SEP/CMAs, and providers
Establishment of communication and feedback loops

11. A Comparison of the Old/New CIRS
Old Incident Types
Suspected Abuse
Suspected Neglect
Suspected Exploitation
Law Enforcement Involvement
Environmental Hazard
Death, expected or unexpected
Emergency services involvement
Medication error
Suicide threats

12. Old/New CIRS New Incident Types Death Abuse/neglect/exploitation
Illness/Injury to Client
Damage to Client’s Property or Theft
Medication Management
Other High Risk Issues

13. Old/New CIRS
Additional descriptors have been added to clarify the nature and circumstances of each incident
Emergency Service and Law Enforcement Involvement should be denoted as a follow-up action with each incident rather than as a distinct incident “type”
Abuse, Neglect & Exploitation have been collapsed into one incident type with specific descriptors for each sub-type

14. Old/New CIRS
Death and Medication Management have been further clarified through the addition of descriptors, providing more detailed information
3 New Incident Types
Illness/Injury to Client
Damage to Client’s Property/Theft
Other High Risk Issues
Other High Risk Issues will be used for unclassified incidents of concern. These may include things like “environmental hazards”, “suicide threats”, BED BUGS, etc. This item will be studied further to determine if additional incident types need to be added later.

15. Review of Reporting Requirements
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 within 1 business day of learning of an incident via the CIRS

16. What Types of Incidents Need to be Reported?
Death
Suspected Abuse, Neglect or Exploitation
Injury to or Illness of Client
Damage to Client’s Property/Theft
Medication Management
Other High Risk Issues

17. Detailed Incident Types
Death
Report any death of an accidental, intentional or suspicious nature or any death, including incidents involving law enforcement or a coroner. If there is any reason to believe the death may be accidental, of a suspicious nature, or NOT due to natural causes, a critical incident should be recorded in the BUS.
Occurrences of death should be reported when it is unexpected or the cause of death is unknown.
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.

18. Detailed Incident Types
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 an adult 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

19. Detailed Incident Types
Injury to or Illness of Client
Injury or illness requiring treatment beyond first aid includes:
illness
lacerations requiring stitches or staples,
fractures, dislocations,
loss of limb,
serious burns,
skin wounds
illness or injury requiring immediate emergency medical treatment; or resulting in emergency admission to the hospital.

20. Detailed Incident Types
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

21. Detailed Incident Types
Medication Management Issues
Problems with medication dosage, scheduling, timing, set-up, compliance, administration or monitoring which result in documented harm or an adverse effect which necessitates medical care

22. Detailed Incident Types
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.
Reports to County Human Services Departments regarding adult or child protection issues or other mandatory reporting.
Environmental Hazards – could include things such as a lack of utilities, a fire, exposure to toxic substances, seriously unsanitary home conditions, damage to home as a result of natural disaster, BED BUGS, etc.

23. Unnecessary or Inappropriate Reporting
If an incident does not fit the incident types of CIRS, yet is deemed to be important by the case manager, note the details of the incident in the log notes of the BUS
In the review of CIRS reports, numerous reports were deemed either unnecessary or inappropriate

24. 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
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

25. Recording a Critical Incident Report
When reporting a critical incident, be prepared to provide enough information so the SEP/CM 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, the follow-up actions taken and referrals made to remedy the situation and ensure the health and welfare of the client.

26. Recording a Critical Incident Report
Timely notification reminder:
Providers must report a critical incident to the HCBS consumer’s Case Management Agency (CMA) within 1 business day of learning of a critical incident
SEPs/CMAs must then report a critical incident to the Department via the BUS within 1 business day of receiving notification of the incident
When a death or serious injury of a client is reasonably suspected to have been directly caused by abuse, neglect or exploitation of the client by a HCBS provider or case manager, the SEP/CMA is expected to report the incident by phone to the CIRS Program Administrator, Solarra Flemister, at the Department immediately upon of learning of the incident. After calling the waiver administrator, the SEP/CMA must record the incident in the BUS.

27. Mandatory Reporting Responsibilities
Reporting Critical Incidents 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.

28. 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

29. After a Critical Incident is Reported
There will be instances when additional follow-up by the SEP/CMA or provider 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’s CIRS Program Administrator, Solarra Flemister, will provide feedback to the SEP/CMA when reports are found to be unnecessary due to the nature of the incident.

30. HCBS Provider Reports to SEP/CMA
The Department does not require any specific method of communication between HCBS Providers 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.
This form can be found on the HCPF website, under Provider Services/Forms/Critical Incident Reporting Forms
It is important for the SEP/CMA agency to make certain the Provider and/or Provider Agency are giving 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.
If providers are not notifying SEP/CMAs in a timely manner or are not providing sufficient info, please notify the CIRS Program Administrator and the SEP contract manager.

31. QUESTIONS???
If you have technical issues related to the CIRS, please use a bus tracker.
If you have questions about what to report, or how to report an incident or need to follow up with someone related to an incident, please contact Solarra