Critical Incident Reporting System CIRS

1. Critical Incident Reporting System (CIRS) Changes, Improvements & Expectations

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

3. 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. What Is a Critical Incident?

4. 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 Why does the State need to track Critical Incidents? Centers for Medicare & Medicaid Services (CMS) Requires: 42 CFR 441.300 � 441.310 Centers for Medicare & Medicaid Services (CMS) Requires: 42 CFR 441.300 � 441.310

5. Monitoring Critical Incidents is a part of the Department�s Global Quality Improvement Strategy encompassing three functions: Discovery Remediation Continuous Improvement Critical Incidents and the Department�s Quality Improvement Strategy 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.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. 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 The Challenge of Maintaining Quality In Waiver Services HCBS waiver service delivery networks are complex. Maintaining and improving quality in diverse service delivery environments while maintaining flexibility is challenging. HCBS waiver service delivery networks are complex. Maintaining and improving quality in diverse service delivery environments while maintaining flexibility is challenging.

7. 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 What drove the changes and improvements to the existing CIRS? 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. 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. 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 What do these findings suggest? These findings may also be an indication of the need for additional training Clarification of the reporting requirement Improvement of the CIRS reporting systemThese findings may also be an indication of the need for additional training Clarification of the reporting requirement Improvement of the CIRS reporting system

9. 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 What has been Changed and Improved? 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 mannerCapturing 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. Establishment of periodic reports and analysis Clarification of expectations for Waiver Program Staff, SEP/CMAs, and providers Establishment of communication and feedback loops Establishment of periodic reports and analysis Clarification of expectations for Waiver Program Staff, SEP/CMAs, and providers Establishment of communication and feedback loops

11. 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 A Comparison of the Old/New CIRS

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. 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 Old/New CIRS

14. 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 Old/New CIRS 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. 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. 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 Review of Reporting Requirements

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

17. 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. Detailed Incident Types 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.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. 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 Detailed Incident Types

19. 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. Detailed Incident Types

20. 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 Detailed Incident Types

21. 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 Detailed Incident Types

22. 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. Detailed Incident Types 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.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. 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 Unnecessary or Inappropriate Reporting In the review of CIRS reports, numerous reports were deemed either unnecessary or inappropriate In the review of CIRS reports, numerous reports were deemed either unnecessary or inappropriate

24. 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 Unnecessary or Inappropriate Reporting Examples

25. 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 Recording a Critical Incident Report 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. 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. 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 Recording a Critical Incident Report 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. 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. 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 Mandatory Reporting Responsibilities Never assume someone else, including the Department, will make or has made the mandated reports on your behalf. Never assume someone else, including the Department, will make or has made the mandated reports on your behalf.

28. 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 After a Critical Incident is Reported

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. 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. 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 HCBS Provider Reports to SEP/CMA 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. 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 Flemister @ 303-866-6921If you have technical issues related to the CIRS, please use a bus tracker.