Processing Special Incident Reports Mini Safety Training

1. Processing Special Incident ReportsMini Safety Training HCA Safety Program

2. HCA Safety Program 405 W. 5th Street, 7th Floor Santa Ana, CA 92701 Tel. No.: 714-834-SAFE (7233) Fax No.: 714-667-8388 E-Mail: HCASafetyProgram@ochca.com Website: http://intranet/safety Business Hours: Monday through Friday; from 8:00 a.m. to 5:00 p.m. Non-Business Hours: After Hours (including Holidays and Weekend) Contact the County Safety Manager Cell No.: 714-981-6288 Meet the Staff: Elsa Davis, DC, REHS Manager FAS/CO/Management Services Vacant Safety & Training Officer ADA Coordinator Support Staff: Estela Ortiz Staff Specialist JoAnn Bowland Staff Specialist Who to call for assistance

3. The purpose of the Special Incident Report (SIR) is to promptly notify the Agency Director and specific Health Care Agency (HCA) programs needing notification of a significant incident that has occurred. • Supervisor or Designee – ensures accurate completion and distribution of all required forms within the mandated timeframes. • Division and/or Program Manager(s)– ensures the supervisor or designee has complied with Agency policies and completed all the corresponding forms in a timely manner. • Office Support Staff – may be asked to type, review or distribute the forms. • HCA Safety Program – Available to assist all HCA programs. Acts as a liaison between CEO Risk Management and/or Cal/OSHA. Although Safety receives a copy of the SIR when it is first initiated, the final original is received and retained in Safety’s repository. Roles in the Process

4. Timely reporting through the SIR process allows the Agency to ensure that prompt action is taken (i.e., reporting to other County and/or State entities of an injury; suspending phone lines; following up on structural repairs to minimize costs; etc.). Note: The SIR is an internal document that is to be circulated and retained within HCA only. The SIR describing the incident must be prepared within twenty four (24) hours of the occurrence by the Agency staff who witnessed the event, or to whom the incident was first reported. For more detailed information on Special Incident Reporting, refer to the HCA P&P: IV-1.03 Special Incident Reporting. Adhering to Timelines

5. The website link to the Special Incident Reporting process is: http://intranet/safety/sir Special Incident Reporting

6. What to look for: Ensure that the appropriate box is marked. Complete all the fields requested on the SIR when reporting employee and client related incidents. Note: Handle all SIRs in a confidential manner. The SIR is an internal document that is to be circulated and retained only within HCA in order to allow for the inclusion of a limited amount of Protected Health Information (PHI) within its content.

7. What to look for: Date Reported to Supervisor. If same as “Date of Incident”, enter again. Date of Incident, this date may be different than the “Date Reported” to the supervisor. Time of Incident – if not known, write “Unknown”. Indicate Location of Incident – if not known, write “Unknown”. Witnesses, If there are no witnesses, write “None”.

8. What to look for: Narrative Description of Incident. Should be brief and to the point. Avoid acronyms to a reasonable extent. (i.e. if most folks know HCA stands for Health Care Agency, it does not have to be spelled out). Medication regimens should not be included.

9. What to look for: Other Information. Employee Related Incidents: Indicate if Workers’ Compensation forms have been provided to the employee. Note: Copies of Workers’ Compensation packet forms should not be attached to the original SIR as it is routed through the chain of command. Attach copies of all the Workers’ Compensation forms to the copy of the SIR that is initially submitted directly to HCA Safety. The original SIR will eventually reach HCA Safety for retention in Safety’s document repository.

10. What to look for: Other Information. Client Related Incidents: Include police or coroner report number, if available. Attach Client Death Letter, if applicable. Attach newspaper article, if available. Note: No other items should be attached to the original SIR as it is routed through the chain of command.

11. What to look for: Name of Person Completing the Form. Phone Number Signature and Date Name of Reviewing Supervisor Phone Number Signature and Date Note: The SIR must be prepared within twenty four (24)-hours of the occurrence. If the supervisor or manager is out; their designee may review and sign to move it along.

12. Additional notifications related to SIRs SIRs cover a wide variety of notification topics. As such, notification to other Agency departments may be required. This may include completion of other forms. Examples: If the SIR involves the loss of a wireless communication device; notify IT and the Wireless Communication Device Coordinator. Refer to HCA P&P V-6.11 Mobile Device Management. If the SIR involves the loss of a laptop or computer; notify IT and the Office of Compliance. Refer to HCA P&P V-1.00 Capital Assets, Equipment and Property Control. If the SIR relates to property damage, security or vandalism issues; notify the on-site building manager and/or file a police report. Refer to HCA P&P V-1.00 Capital Assets, Equipment and Property Control. Note: Reporting Threatening Calls or Altercations – Supervisor makes the determination as to whether the call or situation requires reporting to law enforcement and notification through the SIR process.

13. Prompt completion (within 24-hours) and distribution of the Special Incident Report (SIR) form is important to the Agency. A Special Incident Reporting Fax Cover Sheet to ensure prompt and proper distribution of the SIR is available online at http://intranet/safety/sir. Form Distribution