Massachusetts Rehabilitation Commission (MRC) Department of Developmental Services (DDS)

1. Massachusetts Rehabilitation Commission (MRC) Department of Developmental Services (DDS) HCSIS Incident Management Business Process Training March 2014

2. Training Overview

3. Incident Management Trainings HCSIS/ IM Training User Acceptance Testing Business Process Training This training is one of three learning opportunities: Provides an opportunity to test the system to ensure it meets business requirements. • Provides an opportunity to learn the Incident Management module and how it supports the policies and procedures. • Provides an overview of the Incident Management policies and processes. Overview • Audience includes: • MRC staff • DDS ABI/MFP staff • Shared DDS/MRC providers • MRC-only providers • Audience includes: • MRC staff • DDS ABI/MFP staff • Audience includes: • MRC staff • DDS ABI/MFP staff • Shared DDS/MRC providers • MRC-only providers

4. What is my role here today? • As we are using a train-the-trainer model, we hope that all attendees: • Learn as much as you can today • Bring back your insight to your office • Train any staff who may need to know this information but were unable to attend Agenda • Incident Reporting at DDS and MRC • Incident Report Review Process • Incident Categorization • Incident Categories • Questions?

5. Supporting Training Documents • PowerPoint • Incident Categories • Significant Behavioral Incident Decision Tree • Paper Incident Report • Incident Management Fact Sheet • Incident Scenarios • Incident Management Guidelines

6. Incident Reporting at DDS and MRC

7. What makes a good incident management system? • Identifies adverse events, potential jeopardy and factors related to risk • Notifies key people • Triggers response to protect individual and minimize risk • Closes loop with agreeded upon action steps • Has the ability to collect and analyze information • Has the capacity to identify patterns and trends to guide service improvement • Has thresholds for what is important • Reports important events to key people • Includes levels of review dependent on the severity of the incident Incident Reporting • An incident report must be completed for any incident that can compromise the safety and well-being of an individual • We have moved from incident reporting to incident management

8. HCSIS for Incident Reporting • As of April 14, 2014, MRC staff and select providers will begin using HCSIS for Incident Reporting • MRC providers were selected to use HCSIS based on the number of individuals served and the number of incidents reported • All shared MRC/ DDS providers will begin using HCSIS to report incidents for individuals enrolled to the ABI/MFP waivers • There will be minor differences between the current MRC and DDS incident report and the revised incident report • The incident report form will now be the same for DDS individuals and MRC individuals enrolled to the ABI/MFP waivers • HCSIS will indicate whether or not an individual is supported by MRC or DDS – this is not information the provider or staff will need to input on either the paper or electronic incident report

9. Use of Categories • MRC providers will begin reporting incidents using the current DDS categories, which have been adjusted to include actions that are relevant to the ABI/MFP population • Note that restraints are not allowed under ABI/MFP and would be reported as Suspected Mistreatment Differences in reporting for ABI/MFP individuals • The Incident Reporting process is very similar to what is currently in practice at MRC for individuals on the ABI and MFP waivers, but there are a few key differences: Reporting Unwitnessed Events • Currently, MRC policies state only to report incidents that have been witnessed • Moving forward, all incidents in an individuals’ life will be reported if they meet the criteria for a reportable incident

10. Why HCSIS? HCSIS, the Home and Community Services Information System, supports incident management for DDS and MRC in the following areas: • Promotes consistent collection of data • Provides an integrated system for state agencies and providers • Expedites communications • Automates collection and storage of information • Assists in the identification and remediation of individual events • Allows for analysis of patterns and trends • Helps to identify service improvement activities MRC will begin to use HCSIS for incident management for individuals enrolled to the ABI and MFP waivers on April 14, 2014.

11. Initial Incident Report Final Incident Report The initial incident report is completed immediately after the incident is discovered and can be submitted without all of the event details. There are 7 sections of the intial report: Individual Information Filing Agency Information Incident Classification Incident Description Actions Taken Involved Parties Notifications The final incident report is completed within a week of the initial incident report and fills in any gaps and builds upon the initial incident report. There are 4sections of the final report: Additional Information Action Steps Involved Parties Verifitcation of Time and Categorization Paper Incident Reports and Electronic Incident Reports • The paper incident reports and the electronic incident reports have the same questions and information • Both reports have two sections: • The initial incident report • The final incident report

12. Incident Description Actions Taken Involved Parties Individual Information Filing Agency Information Incident Classification Notifications • Describe the incident in detail • All relevant details • Incident location • The latest status of the individual • Actions taken to protect the health, safety and rights of the individual • What actions were taken • Who took these actions • People involved with the incident • Who completed the incident report • Eyewitneses • Who discovered the report • Individual’s basic information • Name • Address • Service Coordinator/ Case Manager • Filing Agency’s basic information • Agency name • Name of staff who filled out the incident report • Name of staff responsible for follow-up • Incident overview • Date and time of incident • Who was responsible for supervision at the time of the incident • Incident categories • Description of any injury • Who has been informed of the incident • DPPC • DCF • Family/ Guardian • Law enforcement Initial Incident Report Components

13. New Prompts on the Incident Report for DDS Providers • Incident Classification new prompts: • Did the incident involve the unauthorized use of drugs or alcohol? • Did the incident involve suicidal threat/ideation? • Did the incident involve non-compliance with a medical directive? • Did the incident involve non-compliance with medications? • Note: these last two prompts existed on the report previously, but have now been split into two questions • Notificationprompts: • Was the Executive Office of Elder Affairs Notified? • Note: this prompt is only mandatory for individuals who are over age 55 • Was the agency on-call notified? • If “yes,” who was the on-call person notified? • Note: #3 is conditionally mandatory if “Yes” is selected for #2

14. Additional Information Action Steps Involved Parties Verification of Time and Categorization • Any updated or corrected information • Expand upon the previous Incident Description section • Additional action steps assocaited with the incident • Action step details • Target completion date • Responsible party • Any updates or additions to the involved parties • Eyewitnesses • Relationship to the individual • Contact information Verify whether or not the initial report information is accurate and make updates as needed Final Incident Report Components

15. Incident Reporting Steps DDS or MRC Conducts Second Level Review DDS or MRC Conducts First Level Review Incident Discovered Provider Submits Initial Report Provider Submits Final Report An event meets the threshold for a reportable incident – now what? ≤ 3 days ≤ 7 days ≤ 7 days Minor Review Approve OR Not Approve ≤ 1 day ≤ 7 days ≤ 7 days Major Review ≤ 7 days Approve OR Not Approve Approve OR Not Approve

16. Events Requiring a Minor versus Major Level of Review

17. Incident Report Review Process

18. First Level Review DDS or MRC Conducts Second Level Review DDS or MRC Conducts First Level Review Incident Discovered Provider Submits Initial Report Provider Submits Final Report • State agency performs first level review • Review incident • Change category, if needed (except for an unexpected hospital visit) • Approve or reject the incident • Escalate the incident for major level review for incidents that had been classified as minor ≤ 1 day ≤ 7 days ≤ 7 days Major Review ≤ 7 days Approve OR Not Approve Approve OR Not Approve

19. Second Level Review DDS or MRC Conducts Second Level Review DDS or MRC Conducts First Level Review Incident Discovered Provider Submits Initial Report Provider Submits Final Report • State agency performs second level review • Required for all incidents that are designated as major incidents • Applies to incidents of suspected mistreatment with injury or life threatening condition or where staff action exposes individual(s) to serious harm • Applies to all incidents involving law enforcement • Applies to all incidents with potential for negative publicity ≤ 1 day ≤ 7 days ≤ 7 days Major Review ≤ 7 days Approve OR Not Approve Approve OR Not Approve

20. Incident Categorization

21. Secondary Category • Identifies specific types of events within a primary category Incident Categorization Incident categories provide criteria and a threshold for reporting • Primary category • Bullets that define overall category • Secondary category • Expanded information for a specific category • Examples • Certain combinations of primary and secondary categories will require a minor level of review whereas others will require a major level of review • Major and minor describe the level of review, not the incident itself • Major/Minor level of review by State Agency Primary Category Identifies reportable events

22. Choosing a Category When choosing a category, there are a few tips to keep in mind: • Choose only one primary and one secondary category • Review the facts of event carefully and choose category that best fits the predominant component of the event • The incident categories are hierarchical, with the more concerning categories listed first • If you are ever deciding between two categories, opt for the one that appears first in the incident categories document

23. Site Based Incidents • Time saver for providers • Multiple individuals are involved • Impact of the event and the action steps are the same for all individuals involved • Cannot involve injury or illness to individuals involved in the event Types of Incidents There are two types of incidents: Individual Incidents • Incident written for one individual • Must be completed for any event that results in an injury to the individual • If multiple individuals are involved in the event, individual incidents must be created if the event affects all those involved differently

24. Incident Categories

25. Site Based Incident Categories • Transportation accident • Suspected mistreatment • Failure to provide needed supports • e.g. staff does not repair the fire alarm equipment • Failure to provide needed supervision • e.g. staff leaves individuals unattended although no one is harmed • Fire • However, if individuals sets fire purposely or accidentally, that individual needs an individual incident report as well • Emergency relocation • Theft/ alleged victim • Other

26. Individual Incident Categories Review the “Incident Category” document for full definitions

27. Description Secondary Categories • Expected deaths such as someone on Hospice would not be reported through as an incident • Accidental • Suicide • Unusual circumstances • Other unexpected/suspicious death Level of Review • All unexpected/suspicious death incidents require a major level of review Individual Incident: Unexpected/ Suspicious Death

28. Description Secondary Categories • Serious, intentional and voluntary attempt to take one’s life • First known attempt • Repeat attempt Level of Review • All suicide attempt incidents require a major level of review Individual Incident: Suicide Attempt

29. Description • Always used for any unexpected, unplanned visit to the E.R. or emergency psychiatric/drug/alcohol evaluation • Does not include planned hospitalizations • Does not include urgent care visits • Need to carefully identify the reason for the hospital visit: all incident categories can be applied, as well as: • Near drowning • Illness • Injury • Other • Unknown • Requires additional information: • Length of time in emergency room • Admission date and name of hospital • What occurred during the visit • Discharge information • Remains open until the individual is discharged Individual Incident: Unexpected Hospital Visit

30. Individual Incident: Unexpected Hospital Visit (cont’d) Secondary Categories • ER Visit: for medical evaluations without hospitalization • Psychiatric Evaluation: for psychiatric/drug/alcohol evaluations when person is not admitted • Medical Hospitalization: used if an individual is actually admitted to the hospital for a medical need • Psychiatric Hospitalization: used if an individual is actually admitted to a psychiatric hospital, psychiatric unit or detoxification center Level of Review • Unexpected hospital visits sometimes require a major or minor level of review depending on the reason for the visit.

31. Secondary Categories • Aggressive Sexual Behavior (Alleged Victim and/or Alleged Perpetrator): • Used when the victim is a member of the community, includes threats of violent sexual behavior, involves the police, includes actual violent acts (e.g. rape, attempted rape, or use of physical force) • Sexual Misbehavior (Alleged Victim and/or Alleged Perpetrator): • Nonconsensual sexual touching towards another individual and behavior stops immediately when asked or consensual sexual behavior in an inappropriate place Description • Includes unwanted advance, contact or activity • Includes credible threats of rape or violent sexual activity Level of Review • Aggressive sexual behavior incidents require a major level of review and sexual misbehavior incidents require a minor level of review Individual Incident: Inappropriate Sexual Behavior

32. Description Secondary Categories • Victim of attack from another individual receiving services • Event may be minor but very upsetting to the victim • Victim has an additional behavior incident as a result • Victim displays signs of distress that continue for an extended period of time (e.g. crying, screaming, refusing the leave the room) • None Level of Review • All victim of physical altercation incidents require a minor level of review Individual Incident: Victim of Physical Altercation

33. Description Secondary Categories • Behavioral episodes that could result in serious harm • Behavior that can cause public disturbance or a scene • Behavior that involves the police • This can be a difficult category to determine whether or not the incident should be reported, so review the “Decision Tree for Significant Behavioral Incidents” • Questions to help in determination • Chart with guidance for reportable/not reportable events Level of Review • Does not include physical altercation • Includes physical altercation • Note: there are additional questions regarding the identity of the involved parties • All significant behavior incidents require a minor level of review Individual Incident: Significant Behavioral Incident

34. Level of Review Secondary Categories • If law enforcement is contacted, the incident requires a major level of review • If law enforcement is NOT contacted, the incident requires a minor level of review • Law enforcement contacted • Law enforcement not contacted Description • Covers any individual who is missing and considered at risk Individual Incident: Missing Person

35. Description Secondary Categories • Treatment beyond first aid but not involving a hospital visit • Includes urgent care visits • Includes ingestion of non-food items • Includes medication refusals without a plan already in place • Includes suicidal threats, gestures and/or attempts Level of Review • Medical • Psychiatric • All medical or psychiatric intervention incidents that do not require a hospital visit require a minor level of review Individual Incident: Medical or Psychiatric Intervention Not Requiring a Hospital Visit

36. Secondary Categories Description • Alleged started by individual • Includes purposeful and accidental fires • Not started by individual – fire of known origin • Fire of unknown origin • Fire started by the individual always needs an individual incident report for that individual • An event is reportable if the smoke detectors go off because of smoke or malfunctioning fire or carbon monoxide detectors and the fire department comes even if there is no fire • If the incident meets certain criteria related to the secondary incident categories, it could be classified as a site-based incident Level of Review • All fire incidents require a minor level of review Individual Incident: Fire

37. Secondary Categories • Alleged victim of psychological abuse • Alleged victim of verbal abuse • Alleged victim of physical abuse • For individuals enrolled to the ABI and MFP waivers, this incident category should be used for any restraints • Alleged omission of needed supports • Could also be a site based incident • Alleged omission of needed supervision • Could also be a site based incident Description • Includes intentional or negligent action or omission that causes or exposes an individual to a serious risk of physical or emotional harm Level of Review • All suspected mistreatment incidents require a minor level of review Individual Incident: Suspected Mistreatment

38. Description Secondary Categories • Charges are not being filed for the property damage • Value of the damage exceeds $200 or has significant intrinsic value to the owner, such as a family heirloom, causing significant distress • Destruction needs to be deliberate • If another individual is the owner of the property that is damaged, there needs to be 2 incident reports – one for the perpetrator and one for the victim • Alleged victim • Alleged perpetrator Level of Review • All property damage incidents require a minor level of review Individual Incident: Property Damage

39. Description Secondary Categories Level of Review • Individual is the victim or perpetrator of the unlawful taking of money, other financial assets and/or personal property • Incident is reported to DPPC and/or law enforcement • Alleged victim • Alleged perpetrator • If the individual is the perpetrator, the incident requires a major level of review • If the individual is the victim, the incident requires a minor level of review Individual Incident: Theft

40. Description Secondary Categories Level of Review • Any criminal activity reported to law enforcement and is not covered under the incident category of “theft.” • Alleged victim (e.g. an individual being harassed, threatened and/or physical assaulted by someone other than an caregiver) • Alleged perpetrator (e.g. an individual that is arrested for drug possession, stalking or property destruction) • All incidents involving other criminal activity require a major level of review Individual Incident: Other Criminal Activity

41. Description Secondary Categories Level of Review • Covers traffic accidents involving individuals receiving supports when the police are involved • Does not cover minor fender benders with no police involvement • Incident could be a site based incident when the incident affects all individuals involved the same, such as an accident when the police are called and the effect on all involved individuals is the same • Pedestrian • Motor vehicle accident • Other • All transportation accident incidents require a minor level of review Individual Incident: Transportation Accident

42. Description Secondary Categories Level of Review • Individual(s) need to be relocated on an emergency basis for more than 24 hours • Relocation can be for any emergency such as fire, weather conditions, local disaster • Incident could be a site based incident when the incident affects all individuals involved the same, such as an accident when the police are called and the effect on all involved individuals is the same • N/A • All emergency relocation incidents require a minor level of review Individual Incident: Emergency Relocation

43. Description Secondary Categories Level of Review • Individual requires the use of physical holding or a mechanical device to keep him or her safe during transportation that has not been planned for in the individual’s ISP • A restraint form is not required in these circumstances but an incident report is required if the intervention is not written into an individual’s ISP • Examples include a staff needing to hold down an individual to fasten his or her seatbelt so s/he does not grab the steering wheel • N/A • All unplanned transportation restraint incidents require a minor level of review Individual Incident: Unplanned Transportation Restraint

44. Description Secondary Categories • Event does not fit into an existing category but meets the threshold for a reportable event: • Event puts the individual at risk • Key people need to be notified in a timely manner • Response needed for protection and to minimize risk • Should RARELY be used! Level of Review • None • All “other” incidents require a minor level of review Individual Incident: Other

45. Conclusion

46. Incident Reporting Summary The incident reporting guidelines we have covered in this training apply to both the paper incident report and to incident reporting within HCSIS. Using HCSIS for incident reporting provides several benefits for DDS, MRC and provider agencies: • Gives ability to sort data for planning and analysis • Individual • Site • Agency • Area/Region/State • Class Please continue to use your current incident reporting process for all incidents that occur prior to April 14, 2014. After April 14, please use the updated incident report and HCSIS to record incidents for individuals enrolled to the ABI and MFP waivers.

47. Questions? Further information on Incident Management can be found on the DDS website under “Home and Community Services Information System (HCSIS)” and “Incident Management”

48. Conclusion Today we have covered: • Incident Reporting at DDS and MRC • The Incident Report Review Process • Purpose of Incident Categorizations • Review of Incident Categories