HSD/MAD/QB Critical Incident Management System https://criticalincident.hsd.state.nm .

1. HSD/MAD/QB Critical Incident Management System https://criticalincident.hsd.state.nm.us. CENTENNIAL CARE Revised November 1, 2013

2. INCIDENT MANAGEMENT PRINCIPLES • All adults and children receiving Centennial Care services should be able to enjoy a quality of life that is free of abuse, neglect, and exploitation. • Staff must receive initial and ongoing training to be competent to respond to, report, and document incidents in a timely and accurate manner. • Recipients, legal representatives, and guardians must be made aware of and have available incident reporting processes. • Any individual who, in good faith, reports an incident or makes an allegation of abuse, neglect, or exploitation will be free from any form of retaliation. • Quality starts with those who work most closely with persons receiving services.

3. HSD/MAD/QAB Incident Management System • This presentation describes the statewide reporting requirements for incidents involving Home and Community Based Services recipients enrolled in Centennial Care -the new name for New Mexico’s Medicaid Program.

4. Why Report Incidents? New Mexico State law requires reporting alleged incidents. Incident reporting is a mechanism to ensure the health and safety of recipients receiving Medicaid funding.

5. Why Report Incidents? Reporting incidents allows service delivery agencies and Managed Care Organizations (MCOs) to address concerns quickly for health and safety. Incidents are reported to improve service quality by identifying issues or areas of concern. An incident must be reported before it can be investigated.

6. New Mexico Statutes/Regulations • In recognition of the need to report such incidents, the State of New Mexico provides statutes and regulations which define the expectations and legal requirements for properly reporting recipient –involved incidents in a timely and accurate manner.

7. Statutes and Regulations • Adult Protective Services - NMSA 1978, Section 27-7-30 http://law.justia.com/codes/new-mexico/2009/chapter-27/article-7/ • Centennial Care -State of New Mexico Human Services Department Medicaid Managed Care Services Agreement. 4.12.16 Critical Incident Management. • Department of Health - 7.1.13 NMAC http://dhi.health.state.nm.us/elibrary/regs/7.1.13NMAC_Incident_REP_INTAKE.pdf

8. What Types of Incidents Are We Required to Report? All incidents involving: abuse neglect exploitation death-expected or unexpected emergency services L aw enforcement environmental hazards elopement and missing recipients Behavioral Health providers have an additional incident type to be discussed in later slides.

9. Abuse is defined as: Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish [7.1.13 NMAC].

10. Abuse • In the reporting system abuse includes: • Sexual (directed at the recipient) • Physical (directed at the recipient) • Verbal (directed at the recipient) • Self Injury • Sexual Behavior Displayed (directed at the recipient) • Rape (of recipient) • Sexual (recipient towards others) • Physical (recipient towards others) • Verbal (recipient towards others) • Attempted Suicide • Type not specified • Not specifying the type will likely generate a call for more information.

11. Abuse Examples • Recipient is threatened with being homeless or placed in a nursing home. • Recipient is pushed or roughly handled while receiving care. • Recipient is sexually assaulted. • Recipient is made to do without food, water, or bathroom access as punishment.

12. Self-Abuseexamples: • Recipient is doubling up on pain medication and will not see the doctor. • Recipient’s alcohol consumption results in frequent Emergency Room (ER) visits or law enforcement interventions. • Recipient threatens or attempts suicide • Includes cutting self, banging head repeatedly or stepping into traffic.

13. Abuse/Caregiver abuse • Caregiver abuse is important to report. • Seriously impacts the delivery of services • Isolates the consumer • Service coordinator/consultant must be notified. • Description of abuse will be documented in the narrative section of the report.

14. Caregiver abuseexamples: • Sexually harasses caregivers. • Threatens caregivers or their families. • Consistently uses racial or ethnic slurs when talking to caregivers. • Physically pushes, hits or throws things at caregivers.

15. Neglect is defined as: Neglect means the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness [7.1.13 NMAC].

16. Neglect • In the reporting system neglect includes: • Insufficient staffing • Staff not performing assigned tasks • Care not being given by family or others who have agreed to provide support • Self Neglect (refuses food, hygiene, medications including substance abuse and dangerous behavior) • Self Neglect (refusing services) • Type not specified. • Not specifying the type will likely generate a call for more information.

17. Neglectexamples: • Agency frequently fails to provide services that have been authorized. • Staff show up but do not do assigned tasks. • Family or others who have promised support • do not pay the bills • do not purchase sufficient food and supplies • do not arrange or transport to needed medical care • do not provide support as agreed in the personalized service plan for the recipient. (staying overnight, bathing after paid caregiver hours, preparing meals, etc.)

18. Self Neglect Examples: • Does not eat enough to stay well. • Can no longer prepare appropriate meals. • Thinks the food is being poisoned. • Forgets to eat. • Refuses to bathe or change clothes. • Forgets or refuses medications or takes too many at a time. • No heat or electricity because bills are not paid. • Brandishes weapons at neighbors or caregivers. • Shoplifts. • Consistently refuses to allow services to be delivered.

19. Exploitation is defined as: Misappropriation of property (i.e. exploitation) means the deliberate misplacement of consumer’s property, or wrongful, temporary or permanent use of a consumer’s belongings or money without the consumer’s consent [7.1.13 NMAC].

20. Exploitationexamples: • Caregiver uses recipient’s debit card for their own purchases. • People move into the home uninvited and/or without paying for rent or utilities. • Caregiver convinces recipient to sign timesheet for hours not worked. • Recipients medications are frequently missing. • Caregivers or others are taking the recipient’s property (this is exploitation even if the recipient is offering it under duress or as a result of a medical condition such as dementia). • Caregiver borrows money and does or does not pay it back. • Recipient is encouraged or pressured into providing sexual services with or without pay.

21. ExploitationNOTE: • Incidents of exploitation may be also reports of alleged Fraud.(See slides 57-59) • The Alleged Fraud field is selected if a report concerns Medicaid funding that has been paid for services not rendered (e.g. claiming time for work not completed) or for services diverted to inappropriate use(e.g. sale of Medicaid paid goods)

22. Abuse, Neglect and Exploitation (ANE) • Agencies are responsible to report immediate jeopardy incidents to Adult Protective Services (APS) immediately by phone or fax. • MCOs will report all ANE incidents to APS daily. • Any report made to APS must also be a report completed and submitted into the HSD website.

23. Deaths Unexpected Death: any death caused by an accident, unknown or unanticipated cause. Natural/Expected Death: any death caused by a long-term illness, a diagnosed chronic medical condition, or other natural/expected conditions resulting in death.

24. Unexpected Deaths Examples: • Homicide • Suicide • Accident • Death unlikely to be attributed to diagnosis/condition

25. Expected Deaths Examples: • Hospice • Terminal conditions • End stage renal disease • Multiple strokes/heart attacks • Advanced age (more than 90 years old) • Deaths occurring in a facility while in treatment for disease

26. Hospice • If the recipient is in Hospice care the agency will follow the hospice plan of care and will not file neglect for refusing food, medications etc. • A death under the care of a Hospice agency is considered a natural/expected death.

27. Deaths • Deaths are tracked by the MCOs for opportunities to improve services and outcomes of treatment. • Agencies may be requested to provide additional information if needed for these reviews.

28. Deaths • The criteria governing the selection of Unexpected vs. Natural/Expected Deaths is imperfect. • Unexpected Deaths require investigation: • Additional information may be gathered to explain the death which is added to the report. • A referral to Office of Medical Investigation may be appropriate. • Medical records may need to be reviewed.

29. Other Reportable Incidents (ORI) Include: Emergency Services Law Enforcement Intervention Environmental Hazard Missing

30. Emergency Services Emergency Services refers to: A 911 call to the home or location of the recipient (whether or not the recipient is transported) Unanticipated admission to a hospital or psychiatric facility. Emergency room visits whether taken by caregiver, family or EMT (Emergency Medical Transport)

31. Emergency Services Examples of reportable Emergency Services: • 911 is called and the consumer refuses to be transported. • The recipient gets sick at the store and the caregiver takes them to the ER. • The recipient goes to the ER and then leaves before being seen or treated by medical staff. • The ER releases the recipient without providing any treatment.

32. Emergency Services Examples of NON REPORTABLE Emergency Services: • The recipient is at the doctor, gets sick and the doctor sends them to the ER. • The recipient is admitted to the hospital for a scheduled treatment or observation. • An ambulance is used for transportation for either a scheduled physician visit or to the hospital for a scheduled procedure.

33. Law Enforcement Law Enforcement Intervention refers to: the arrest or detention of a person by law enforcement involvement of law enforcement in an incident or event transportation of a person to a hospital or correctional facility.

34. Law Enforcement Examples: • Police are called to the recipient’s home because of a disturbance (even if the consumer is not causing the disturbance). • The recipient is arrested and/or incarcerated. • The recipient is picked up for a bench warrant or parole violation (even if they are released). • The police are called to do a ‘well check’ (even if they find them ‘well’). • The police are called because the recipient is creating a disturbance. • A person is detained in Protective Custody. • A person is transported by police to a hospital or mental health facility, voluntarily or involuntarily or through an involuntary treatment court order.

35. Law Enforcement NOTE: Law Enforcement involvement for a caregiver is NOT an a reportable incident. However, there may be a reportable incident if • The caregiver has harmed or robbed the recipient. • The caregiver being detained or incarcerated results in services not being delivered. • The caregiver is also the natural support and is not available to provide health and safety supports.

36. Environmental Hazard Environmental hazard refers to: An unsafe condition which has created or may create a threat to life or health or safety for the recipient or the caregiver.

37. Environmental Hazards Examples: • A fire or flood has created a hazard in the home. • Animals are out of control at the home • Threatening services • Creating more waste that can be cleaned timely. • Lack of repairs that create hazards • Lack of water, electricity, heat that was in place previously • Wood heat or hauled water is not considered a hazard. • Holes in the floors • Roofs that leak • Windows and doors broken • Debris not cleared. • Foul smells, piles of garbage, standing dirty water, etc.. • Clutter that impedes normal movement to bathrooms or exits.

38. Environmental Hazards • Examples continued: Drugs, guns and dangerous people! • Blatant illegal drug use or visible evidence of the manufacture or sale of drugs. • Guns that are not secured and/or are brandished by the recipient or others in the home. • The recipient or others in the home threaten, frighten or harm caregivers or others providing services.

39. Environmental Hazards • The following are NOT environmental hazard incidents: • The home is heated with wood (and has a functioning stove and ventilation) • The home does not have running water (and the home has systems to provide safe potable water for use). • Clutter is contained and does not impede function of the home or safe passage of the individual and caregiver.

40. Missing • Elopement • Primarily a Behavioral Health incident type • Occurs when someone is required to be somewhere and then leaves without permission or alerting others • Wandering • Used for those recipients who leave without intent to stay gone. May be lost or unaware of their surroundings. • Not to be used for those who have intentionally left their residence without telling anyone. Those reports will be filed as “missing” without a secondary incident type.

41. Submitting an Incident Report • Incident reports must be submitted for recipients of Centennial Care through the web site for the HSD Incident Reporting System: https://criticalincident.hsd.state.nm.us. • Incidents must be reported within 24 hours of knowledge of the incident. • Incidents must be reported accurately. • Incidents must be reviewed by the agency and the MCO to determine if follow up is needed.

42. Submitting an Incident Report • Agencies that do not comply with incident reporting requirements are in violation of state statute and Medicaid regulations, and may be sanctioned up to and including termination of their provider agreement by an MCO or by the HSD, Medical Assistance Division.

43. Who Completes an Incident report? • The agency delivering an authorized service submits the incident report within 24 hours of knowledge of the occurrence. • The MCO submits an incident within 24 hours of an occurrence discovered during MCO/recipient activities (assessment, phone call, etc.). • The Financial Management Agent (FMA) submits an incident for recipients with Self Directed Services if the FMA discovers an alleged incident or receives a call from the recipient. • An interested person may call or write an agency or MCO and report an incident anonymously. The agency or MCO will then submit an incident based on the information received.

44. Incident Reporting for recipients of Centennial Care Self Directed Services follows the same processes and procedures as other incident reporting. • Reports will be made by the MCO Support Broker or Service Coordinator, any provider of services or by Fiscal Management Agent staff. Self Directed Services

45. The FMA is unique when reporting incidents: • The FMA does not deliver services. • The FMA does not maintain a ‘primary file’. • The FMA does not directly address any of the issues reported. • The FMA is the only agency that ALL Self Direction recipients utilize. • Maintaining accurate and complete information is a challenge. • IF the FMA does not have the required information, they will state “not available to FMA” • Medications, diagnoses, etc • The FMA must share all the information they DO have. • Name of MCO • Accurate demographics • SS# • Address, phone, etc • Date of birth • Name and phone # of employee/caller Self Directed FMA is ‘Special’

46. Behavioral Health Critical Incidents • Behavior Health Services are integrated into Centennial Care. • Behavioral Health Agencies have additional functions to complete when submitting a report. • Critical Incidents submitted to the database by Behavioral Health Providers include those reported by the provider and those reported to the provider by agency staff or family.

47. Behavioral Health Critical Incidents • When a Behavioral Health (BH) provider opens a report to complete, the agency’s name will self populate. • The agency is recognized as a BH provider and two functions become enabled: • A diagnoses dropdown box • A treatment location type drop down box • Also one additional incident type becomes enabled.

48. Behavioral Health Critical Incidents • Diagnoses Drop Down • Only a primary diagnoses will be selected • All other diagnoses relevant to the report can be added to the free text diagnoses field. • Treatment Site Drop Down • This is the site/service that the reporter works for at the time of the incident. • The additional provider information (address, phone) will be entered in the appropriate fields.

49. Behavioral Health Critical Incidents • Many people receiving Centennial Care services have behavioral health diagnoses. • Only the Behavioral Health Agencies will enter BH Critical Incidents. • When other Centennial Care agencies open a report to complete, the BH functions are not available and the report can be completed as usual.

50. Behavioral Health Critical Incidents An incident that is reported by a BH provider may be related to incidents for the same recipient submitted by other Centennial providers. These are not duplicates.