Critical Incident Reporting System (CIRS)

Critical Incident Reporting System (CIRS) Linda Metzger Colorado Department of Health Care, Policy & Financing

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 had a negative impact on the mental and/or physical well being of a client in the short or long term. What Is a Critical Incident?

Persons with Brain Injury (BI) • Persons with Mental Illness (MI) • Persons Living with AIDS (PLWA) • Elderly, Blind & Disabled (EBD) • Persons with Spinal Cord Injury (SCI) • Children with Life Limiting Illness (CLLI) • Children’s HCBS (CHCBS) • Children with Autism (CWA) Applicable Waiver Programs

To assure that necessary safeguards have been taken to protect the health and welfare of the individuals receiving 1915c waiver services • To identify, address and seek to prevent the occurrence of abuse, neglect and exploitation on a continuous basis • To comply with key regulatory requirements from CMS regarding monitoring • To insure remediation (follow up) actions are initiated when appropriate Why does the State need to track Critical Incidents?

Monitoring Critical Incidents is a part of the Department’s Global Quality Improvement Strategy encompassing three functions: • Discovery • Remediation (Follow-Up) • Continuous Improvement Critical Incidents and the Department’s Quality Improvement Strategy

Waiver services are furnished at widely dispersed sites throughout the community • Typically include: large and small private-sector provider organizations, assisted living facilities, adult day care facilities, case managers, individual personal assistants and attendants, clinicians, neighbors and other community members who support individuals Providers of Waiver Services

There was a significant increase in reporting over the past 3 years. • 2009 100/month • 2010 150/month • Jan.-June 2011 200/month • July-Dec. 2011 300/month • Jan.- July 2012 500/month Number of Critical Incidents Reported per Month

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 Reporting Issues

Timely Reporting Requirements HCBS Waiver Service Provider Case Manager ( within 24 hours or one business day) Case Manager HCPF (BUS) ( within 24 hours or one business day) Follow-up and investigation Case Manager responsibility? Provider responsibility? Other entity Responsibility?

www.colorado.gov/hcpf Provider Services>provider services>forms>Critical Incident reporting systems forms 1.HCBS Provider Critical Incident Information Form 2. Provider Critical Incident Follow-Up Form Provider Reporting Forms

Death • Suspected Abuse/Neglect/Exploitation • Serious Illness • Injury to Client • Damage to Client’s Property or Theft • Medication Management • Other High Risk Issues Types of Critical Incidents to Report

Death Types • Ongoing Medical Condition/Illness/Disease • New Medical Condition/Illness • Unexpected/Unknown Cause • Completed Suicide • Homicide • Accidental Death • Other

Abuse includes actions which result in bodily harm, pain or mental distress. • Neglect is a failure to provide care and service when a waiver client 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. Suspected Abuse, Neglect or Exploitation

Recurring Illness • Heart attack (MI) • Stroke (CVA) • Pneumonia • Respiratory failure • Seizure • Infection (UTI) • Dehydration • Cancer • Diabetic Crisis • Mental Illness symptoms • Medical crisis • Other illness Serious Illness/Medical Crisis

Cause of Serious Illness • New medical condition • Existing medical condition • Treatment error • Medication • Poor care • Undetermined • Other

Fracture/Dislocation • Laceration • Serious Burn • Head Injury • Multiple injuries • Unknown injury from fall requiring medical attention • Unknown injury • Other injury Serious Injury

Fall • Accident • Seizure • Assault • Choking/Aspiration • Physical Restraint • Undetermined • Other Cause of Serious Injury

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 Damage to Client’s Property/Theft

Problems with medication dosage, scheduling, timing, set-up, compliance, administration or monitoring which can result in documented harm or an adverse effect which necessitates medical care. • Event Type • Cause for event • Administered by Medication Management

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. • This type of critical incident always requires follow-up. Other High Risk Issues

Lost/missing person • Loss of Home/Eviction • Client fraud • Provider fraud • Serious criminal offense (offense by client) • Client abuse toward others • Unusual aggressive behavior Types of High Risk Issues • Suicide ideation • Suicide attempt • Substance abuse • Media involvement • Environmental hazard • Restraints used

Common Reporting Items 1. Hospitalizations2. ER Visits3. Dr. Visits4. Law Enforcement Involvement

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, no ER visit • 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

When reporting a critical incident, be prepared to provide enough information so the reviewer 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

Reporting Critical Incidents in the BUS 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

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

There will be instances when additional follow-up by the SEP/CMA 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 After a Critical Incident is Reported

After you login to the BUS, identify the client for report entry Entering a CIR in the BUS

CIRS – Entering a Critical Incident After you verified you have the correct client, click on “Critical Incident Reports”

CIRS – Entering a CIR You can click on “Add New CIRS” or “Add Critical Incident” to start the entry process

CIRS – Entering the incident info Make sure all elements are completed

Definition of what types of events are appropriate for each incident type CIRS – Incident Specific Descriptors Complete a thorough description of the incident circumstances Complete the incident specific descriptors

After completing the incident descriptors, click “Persons Involved” CIRS – Persons Involved Complete the sections for name, relationship to client, and role Click “Add” to enter additional persons involved

After completing Persons Involved, click on Mandatory Reporting Steps CIR – Mandatory Reports Made Make sure all sections are complete Click “Add” to enter additional mandatory reports made

After completing Mandatory Reporting Steps, click on Follow-up Actions Taken Make sure follow-up actions are complete. This section describes the actions take to remedy the situation and/or secure the client’s health and welfare CIRS – Follow Up Actions Click “Add” to enter additional follow up actions

After Follow-up Actions, click on Referrals Made Complete a referral screen for each referral completed in relationship to the incident that occurred. Please be descriptive of actions take and reason for referral CIRS – Referrals Made

After completing Referral Steps, click on Persons Notified CIRS – Persons Notified Complete all sections of the person notified Click “Add” to enter additional persons notified

Select Post Report Follow-up to document additional incident related information CIRS – Post Report Follow-up Provide narrative description of additional information

The Department does not require any specific method of communication between HCBS Provider Agencies 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. HCBS Provider Reports to SEP/CMA

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Critical Incident Reporting System (CIRS)