HSD/MAD/QAB Incident Management System

1. HSD/MAD/QAB Incident Management System

2. Why Report Incidents? New Mexico State law mandates requirements for reporting alleged incidents. Incident reporting is a mechanism to ensure the health and safety of consumers receiving Medicaid services.

3. Why Report Incidents? Incidents are reported to improve service quality by identifying issues or areas of concern. An incident must be reported before it can be investigated.

4. INCIDENT ANAGEMENT PRINCIPLES • All adults and children receiving Home and Community Based 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 • Consumers, 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.

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

6. List of Statutes and Regulations • Adult Protective Services - NMSA 1978, Section 27-7-30 http://law.justia.com/codes/new-mexico/2009/chapter-27/article-7/ • Department of Health - 7.1.13 NMAC http://dhi.health.state.nm.us/elibrary/regs/7.1.13NMAC_Incident_REP_INTAKE.pdf • Personal Care Options - 8.315.4.12 NMAC B. (14), (15) http://www.hsd.state.nm.us/mad/pdf_files/provmanl/prov83154.pdf • CoLTS ‘C’ Waiver - 8.307.18.10 NMAC E. http://www.nmaging.state.nm.us/pdf_files/CoLTS-provider-pdfs/8_307_18_CoLTS_C_Regulations.pdf • Mi Via Waiver - 8.314.6 NMAC http://www.hsd.state.nm.us/mad/pdf_files/provmanl/prov83146.pdf

7. HSD/MAD/QAB Incident Management System • This presentation and the Incident Management Guide describes the statewide reporting requirements for all incidents involving consumers served under certain Medicaid-funded, Home and Community Based service programs. • These programs include • CoLTS ‘C’ Waiver, • Personal Care Option Program (PCO) • Mi Via.

8. What Types of Incidents Are We Required to Report? All incidents involving: abuse, neglect, and exploitation, natural or unexpected deaths, emergency services, law enforcement, environmental hazards.

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 • Consumer is threatened with being homeless or placed in a nursing home. • Consumer is pushed or roughly handled while receiving care.

11. Abuse/Self Abuse • Abuse includes self abuse • Agencies may write in “self-abuse” • Self abuse will be documented in the narrative section.

12. Self-Abuse • Consumer is doubling up on pain medication and will not see the doctor. • Consumer’s alcohol consumption results in frequent ER visits or law enforcement interventions.

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

14. 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].

15. Neglect • Caregiver/family do not provide sufficient food or do not allow others to provide food. • Medical appointments and treatments are routinely not attended. • The home is not warm or cool enough.

16. Neglect/Self Neglect Neglect includes self neglect. Agencies may write in “self-neglect”. Self neglect will be documented in the narrative section.

17. Self Neglect • Not eating enough to stay well. • May be ill • May believe someone is poisoning the food • Refuses to bathe or change clothes. • Forgets or refuses medications • No heat or electricity because bills are not paid.

18. 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].

19. Exploitation • Caregiver uses consumer’s debit card for their own purchases • People move into the home uninvited and without paying for rent or utilities • Caregiver convinces consumer to sign timesheet for hours not worked

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

21. Unexpected Deaths • Homicide • Suicide • Accident • Death unlikely to be attributed to diagnosis/condition • Cerebral palsy, mental health diagnosis, cognitive delay, brain injury, etc

22. Expected Deaths • 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.

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

24. Emergency Services Emergency Services refers to admission to a hospital or psychiatric facility or the provision of emergency services that results in medical care which is unanticipated and/or unscheduled for this individual and which would not routinely be provided by a community based service provider.

25. Emergency Servicesreport this: • 911 is called and the consumer refuses to be transported. • The consumer gets sick at the store and the caregiver takes them to the ER. • The consumer goes to the ER and then leaves after checking in but before being seen. • The ER releases the consumer without providing any treatment.

26. Emergency ServicesDO NOT report this: • The consumer is at the doctor, gets sick and the doctor sends them to the ER. • The consumer 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.

27. Law Enforcement is defined as: Law Enforcement Intervention is the arrest or detention of a person by law enforcement, involvement of law enforcement in an incident or event, or placement of a person in a correctional facility.

28. Law Enforcement • Police are called to the consumers home because of a disturbance (even if the consumer is not causing the disturbance) • The consumer is incarcerated. • The consumer 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 consumer is creating a disturbance.

29. Law Enforcement 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 consumer • 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.

30. Environmental Hazards is defined as: An unsafe condition which creates an immediate threat to life or health.

31. Environmental Hazards • 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 • Frayed, broken or trailing live wires • Clutter that impedes normal movement to bathrooms or exits.

32. Environmental Hazards • Drugs, guns and dangerous people • Blatant illegal drug use or visible evidence of the manufacture or sale of drugs • Guns that are not locked up and/or are brandished by the consumer or others in the home. • The consumer or others in the home threaten, frighten or harm caregivers or others providing services.

33. Submitting an Incident Report • Reporting abuse, neglect or exploitation to the MCO and HSD does not relieve a provider of mandated reporting requirements to Adult Protective Services (APS). • Incident reports must be submitted to the Consumer’s Managed Care Organization (United Healthcare or Amerigroup) and HSD/MAD/QAB within 24 hours of knowledge of the incident.Report all incidents within 24 hours! If the incident occurs on a weekend or holiday the incident must be reported on the next business day. • Description of the actual incident should always be provided by the person with the most immediate knowledge of the incident. • All incidents pertaining to the HSD programs described in this document should be reported using the Human Services Department’s Incident Report form and are submitted to HSD via FAX at (505) 827-3195.

34. 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.

35. Who Completes an Incident report? • The agency is required to submit a completed • report. • The person with the most immediate • knowledge of the incident completes or • provides the information for Section 2. • Any staff, employee or consumer may • complete an incident report anonymously.

36. The Adult Protective Services Act Mandates any person having reasonable cause to believe an incapacitated adult is being abused, neglected or exploited shall immediately report that information to Adult Protective Services.

37. APS Reporting Requirements Providers shall report to APS: Abuse, Neglect, Exploitation, And deaths suspected to be a result of ANE. Abuse, neglect, exploitation, deaths, emergency services, law enforcement involvement, and hazardous environments to: the appropriate MCO, (Amerigroup or United Healthcare) and copies to HSD/MAD/QAB (Report all incidents within 24 hours! (Next business day in the event of weekend or holiday).

38. APS REPORTING GUIDELINES • First and foremost, always ensure the safety of the consumer! • The New Mexico Adult Protective Services (APS) Act mandates: Any person having reasonable cause to believe an incapacitated adult is being abused, neglected, or exploited shall immediately report that information to the department.

39. Deaths Reported to APS • Deaths that are suspected of being related to abuse or neglect must be reported immediately to APS. • Deaths that are the result of natural causes and/or are expected donot need to be reported to APS. • If the death occurs outside of a medical facility, local law enforcement must be notified.

40. APS Procedure • APS will screen all incident reports and make a determination whether investigation is warranted. • If the incident involves a criminal act, local law enforcement must be notified immediately. • Law enforcement must be notified by the person reporting the incident. • When the incident is reported to APS, if law enforcement has not been notified APS will notify law enforcement.

41. Adult Protective Services Statewide Central Intake Incidents involving suspected/alleged abuse, neglect, and exploitation must be referred immediately to: Telephone: 866.654.3219 FAX: 505.476.4913

42. Critical Incident Reporting Flow Chart

43. HSD Incident Report Form with Numbers and Instructions

44. HSD Incident Management Sample Form

45. HSD Incident Management Form

46. Where Do We FAX • Incident Reports? • CoLTS ‘C’ Waiver, • Personal Care Option Program (PCO) • Mi Via. • APS Fax: 505-476-4913 • CPS Fax : 505.841.6691 • HSD/MAD/Quality Assurance Bureau • Fax: 505-827-3195 • Amerigroup Fax: 1-866-920-8354 • United Healthcare Fax: 1-866-751-2448

47. Where Do We FAX Incident Reports? Other programs: DOH/DHI/IMB: (Developmental Disability Waiver & Medical Fragile) Fax: (800)584-6057 DOH/DHI/HFLC: (Licensed Home Health, Assisted Living Facilities and Nursing Facilities) Fax: (888)576-0012 * If the Home Health patient or the Assisted Living resident is a member of CoLTS C, PCO or Mi Via the report ALSO goes to HSD/MAD/QAB Fax: 505-827-3195.

48. Fraud Alleged Fraud is reported as follows: • Follow the critical incident reporting process for all cases of Abuse, Neglect and Exploitation • Clearly mark as Exploitation/Alleged Fraud and fax form to 505-827-3195 • You may also send an email to matthew.quintana@state.nm.uswith “Alleged Fraud” in the subject line • or call 505-827-3146.

49. HSD/MAD/QAB Contact Information If you have questions about any of the forms or the content of this guide you may send a Fax to: 505-827-3195 You will receive a response to your questions within 48 hours. Please allow additional time for weekends and holidays.

50. HSD Incident Management System FAQ/Best Practices • What about multiple reports? • What about the consumer who demands that a report be created about the same thing over and over? (e.g. Accusing a previous caregiver of stealing) Develop a policy and procedure for the organization (and shared with consumers) that states multiple report requests will be reviewed and will be reported to the state on a monthly basis as one report. Make a documented call/memo to the consumer’s consultant, service coordinator or guardian sharing the issue and requesting assistance for the consumer to understand the purpose of incident reporting and to assist the consumer to resolve any issues in services.