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1. Divider slide For Providers Incident Reporting

2. 2 Types of Incidents Immediately Reportable Sentinel Homicide Suicide Accidental or otherwise unexpected death Death/Injury sustained from behavioral intervention, fire, elopement, loss of limb Sexual Assault/Rape Abduction Critical Suicide Death (natural) Emergency Medical Treatment Hospitalization due to injury or medication error Arrest Risk Actions taken by customers that cause harm to themselves Actions taken by customers that cause harm to others

3. Immediately Reportable Events This type needs to be sent to SWMBH within 48 hours of the event happening Can be, but not limited to: • A critical/sentinel event covered in the media • Suspicious Deaths • Relocation of any customer placement due to licensing suspension or administration • Conviction of CMH/Provider employee related to job performance or responsibility

4. Sentinel Incident (Event) An “unexpected occurrence” involving death (not due to the natural course of a health condition) or serious physical or psychological injury or risk thereof. Serious injury specifically includes permanent loss of limb or function. The phrase “or risk thereof” includes any process variation for which recurrence would carry a significant chance of a serious adverse outcome. Any injury or death that occurs from the use of any behavior intervention is considered a sentinel event.

5. Critical Incident (Event) An incident that meets the state reporting definitions defined by the MDHHS/PIHP contract attachments, which include: • Suicide(for all active customers*) • Non-Suicide Death (only for specific populations) • Specialized Residential facility • Child-Caring institution • receiving community living supports • supports coordination • targeted case management • ACT • Home-based • Wraparound • Habilitation Supports Waiver • SED waiver or Children’s Waiver services • Emergency Medical treatment due to Injury or Medication Error (only for specific populations – see above) • Hospitalization due to Injury or Medication Error (only for specific populations – see above) • Arrest of Consumer (only for specific populations – see above) • Injury as a result of physical management (only for specific populations – see above) *Suicide for any individual actively receiving services at the time of death, and any who have received emergency services within 30 days prior to death. Once it has been determined whether or not a death was suicide, PI must report the suicide within 30 days after the end of the month in which the death was determined.

6. Risk events are occurrences that do not meet the classification requirements of “critical” or “sentinel” but may put a customer at risk of such level of harm. These events minimally include the following: • Actions taken by individuals who cause harm to themselves • Actions taken by individuals who cause harm to others • Two or more unscheduled admissions to medical hospital (not due to planned surgery or the natural course of a chronic illness, such as when an individual has a terminal illness) within a 12 month period. Risk Event

7. Everything Leads to PI

8. DO! • Submit IR to Performance Improvement within 24 hours or next business day • Fax 269-966-2844 • Use another sheet of paper if you run out of room • Fill out everything that you can! • Be specific • If handwriting, print legibly • Provide customer number DON’T! • Do not put multiple occurrences on one IR (i.e., med refusal morning and evening), separate them out • Do not put more than one customer full name on IR, use initials of other customers • Do not completely scratch out a word. Cross it off with one or two lines through the word and initial

9. Physical Management In addition to an IR, a use of Physical Management Form MUST be completed and sent to PI.

10. What is NOT a Reportable Incident to Summit Pointe Performance Improvement… Incidents that happen to other CMHP clients Recipient Rights Violations- go directly to RR! Behaviors that are already documented in behavior tracking sheets

11. What do we do with this information??? Immediate Event Notification Notifies SWMBH ASAP Sentinel Event (Root Cause Analysis) PI reviews the event – usually initiating a RCA Critical Incident Report Uploads the report to SWMBH monthly Risk Event Report Reviews events for trends, sends higher risk events to SWMBH Root-Cause Analysis (RCA)- A method of review aimed at identifying the root causes of problems or events. The practice of RCA is predicated on the belief that problems are best solved by attempting to address, correct or eliminate root causes, as opposed to merely addressing the immediately obvious symptoms. Within three days a determination will be made if it meets the sentinel event standard, if it does meet that standard the organization has two days subsequent to start the root cause analysis. Action Plan: The product of the root cause analysis that identifies the strategies, individual(s)/department(s) responsible for the action, and target dates for completion that the organization intends to implement to reduce the risk of similar events occurring in the future. Follow-Up to Root Cause Analysis: Documentation that action has been taken to correct the causes identified and that the action plan has been implemented.

12. Critical events reported to PIHP (SWMBH) and State – see handout/attachment

13. Risk Events reported to SWMBH

14. Risk Event Categories

15. Large Photo Slide 15 IR Examples - Matching RISK Event for both customers Sentinel Event Critical Incident Not a Reportable Event RISK Event for other affiliate member Reportable event-Risk Event Immediate Event Notification • Direct Care Worker calls police due to our member throwing a chair through a window and locking themselves in their room • Male running around specialized residential home with a knife chasing another resident (also a member of our affiliation). • Male cuts off own finger (Waiver customer) • Customer in specialized residential punches staff person, staff person has bruise on arm • Consumer punches another affiliate member in same setting • Member receiving outpatient services kills family and takes hostages. • Police called to CCI for our member due to our member’s behavior

16. Best Practices • If a particular behavior is persistent: communicate with the customer’s case manager to help incorporate into next (or create a new) behavior treatment plan • Share your BEST PRACTICES!!! 

17. THANK YOU Performance Improvement Team Performance Improvement Coordinator Bridget Avery Performance Improvement Coordinator Katie Larder 269-441-6056 269-441-6025 bma@summitpointe.org kll2@summitpointe.org