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HomeMy WebLinkAboutIDD-505 Risk Mitigation1 FRANKLIN/FULTON COUNTY MENTAL HEALTH/INTELLECTUAL & DEVELOPMENTAL DISABILITIES/EARLY INTERVENTION 425 Franklin Farm Lane Chambersburg, PA 17202 (717) 264-5387 MH/IDD/EI PROCEDURE STATEMENT PROCEDURE SUBJECT: Risk Mitigation (Incident Management & Human Rights Committee) PROCEDURE NUMBER: IDD-505 Effective Date: July 1, 2008 Date Revised: October 19, 2023 Reference: Bulletin 00-21-02 “Incident Management”, AE Operating Agreement, ODP Communication Number: Packet 031-15 INTRODUCTION: In establishing a consistent statewide process to safeguard individuals registered with the Intellectual & Developmental Disabilities Program, Franklin/Fulton MH/IDD/EI will follow the guidelines set forth by the Office of Developmental Programs (ODP) in Bulletin #00-21-00 and the Administrative Entity (AE) Operating Agreement. INCIDENT MANAGEMENT All providers of Intellectual & Developmental Disabilities services and supports, including ICF/ID, who receive funds from the Intellectual & Developmental Disabilities system either directly or indirectly are reporters and must file incident reports as outlined in the bulletin. The primary goal is to ensure that when an incident occurs, the response will be adequate to protect the health, safety, and rights of the individual. As outlined in the bulletin, all reportable incidents are to be submitted electronically via the Enterprise Incident Management System (EIM) within the required time frames as outlined in the bulletin. In the event that EIM is unavailable, the submission of incidents is to occur as per the Incident Management Contingency Plan. General MH/IDD/EI Staff Responsibilities for Incident Management: The Program Specialist/County Incident Manager is the primary staff assigned for the coordination of activities related to Incident Management. In the absence of the Program Specialist/County Incident Manager, another Program Specialist will be designated to perform this function or ongoing functions as assigned by the MH/IDD/EI Administrator. 2 The Program Specialist/County Incident Manager will complete quarterly reporting of Incident Management data analysis for the purpose of identifying potential systematic issues related to health, welfare, and impact on individual rights during Risk Management review meetings. The Program Specialist/County Incident Manager will also monitor the Incident Management Process for Providers via Incident Reviewing, coordinate Certified Investigators activities for county required and desired investigations, and assist in other Incident Management roles as needed, such as providing required reports for the peer review of investigations process, ODP incident fidelity/homework activities, and follow up on Adult Protective Service reports of need. Receipt and review of Incident Management reports: The assigned County Incident Reviewer delegated to the County contracted provider will read and review all incident reports filed to determine that appropriate actions to protect the individual’s health, safety and rights have occurred. If the Incident Reviewer has any problems or concerns with the incident report, follow-up/corrective action will be requested of the provider filing the report. Supports Coordinators will take the following steps when reviewing/following up on incidents reported for consumers on their caseload:  Review the “Initial Notification/First Section Submitted” of all filed incidents.  Enter service note in record of receipt and review of report and major points of report when necessary.  Follow-up/make contact with Provider, as needed and document contact with provider in service note and within the EIM report.  Review the “Incident Report/Final Section Submitted” and enter service notes and document within the EIM report any other additional pertinent information from report when necessary. Additionally, the County Incident Reviewer will review the EIM first section submission daily including weekends and holidays. The County Incident Manager and Reviewer will also pull EIM reports on a monthly basis and notify appropriate Provider agencies needing to finalize outstanding incident reports. All incidents must be finalized within 30 days of the first section submission or an extension must be requested as outlined in the bulletin. All incident reports must be “closed” by the County Incident Manager and Reviewer through an approval process of the incident. This process will include a determination that: the appropriate action to protect the health, safety and rights of the individual occurred; the incident categorization is correct; a certified investigation occurred when necessary; proper safeguards are in place; and corrective action in response to the incident has, or will, take place. Assignment of Certified Investigators: The Program Specialist/County Incident Manager will coordinate Certified Investigators to investigate all incidents that are: deemed to require investigation by the County; or investigating an individual not in the employ of the provider (i.e., family member); and when MH/IDD/EI feels an incident investigation is needed. 3  The Certified Investigators will conduct investigations based on the Certified Investigator Training course.  The Certified Investigators will complete a written report that will include a summary of all findings, evidence and statements gathered and add this summary to the EIM report.  At a minimum, quarterly peer reviews from a sample of the investigations completed on behalf of the AE will be completed per the Certified Investigator Peer Review (CIPR) Manual. Immediate Incident Notification to the Administrative Entity (AE):  Administrative Entity is Franklin/Fulton MH/IDD/EI Providers will directly speak with the AE via telephone within two (2) hours of the occurrence for the following incidents:  Rights violation: unauthorized restrictive procedure  Exploitation  Medical responsibilities, room & board, unpaid labor  Abuse: misapplication/unauthorized use of restraint (injury)  Death Directly speak with AE means that the provider will verbally speak to a live representative of the AE. Please follow the call chain listed until you reach a live person. Monday through Friday 8:30 a.m. – 4:30 p.m. excluding holidays and weekends. 1. Franklin/Fulton MH/IDD/EI (717) 264-5387 Hours outside those noted above, please call in the following order until you reach a live person. Please also leave a message on each phone you call. If you have called everyone on the list and left a message, but did not reach a live individual you have completed your responsibility. 1. Stacey Brookens – Administrator: 717-377-0876 2. Marion Rowe - Program Specialist/County Incident Management: 516-567-1966 3. Jane Cline - Program Specialist: 717-262-8128 4. John Gerak – Program Specialist: 717-860-3052  The AE staff receiving the call will take the necessary measures to assure the individual’s health and safety.  If the incident requires an investigation or is not required but desired, the AE staff receiving the call will coordinate an investigator within 24 hours of receiving the incident notification. When MH/IDD/EI receives reports from individuals, families, citizens, or other entities not reporting in EIM:  When individuals, families and/or other entities report incidents of abuse, neglect, and death to MH/IDD/EI or the Supports Coordination Organization (SCO), the SCO will initiate the filing of the “Initial Notification/ First Section Submitted” report in EIM within 24 hours of receiving the verbal report if the incident is not associated with the provision of a provider delivered service. The SCO Point Person will take the necessary measures to assure the individual’s health and safety. 4  The SCO Point Person will contact the necessary parties (i.e. individual and person’s designated by the individual, Older Adult Protective Services, Adult Protective Services, ChildLine/Child Protective Services, Department of Aging, Department of Human Services, Department of Health) related to the incident, if applicable.  If the incident requires an investigation, the SCO will contact the AE for a Certified Investigator assignment.  The Point Person must also complete the “Final” report for the incident which includes development of the preventative corrective action plan.  The Point Person will notify families/ individuals of the outcomes of investigations. Release of incident information:  At the request of the individual or persons designated by the individual, incident information may be released. This information will include: a summary/description of the incident, incident classification, action taken to protect health and safety, date and person or entity notified, findings/determination, as well as corrective action and any medical intervention.  Any information about another individual and the reporter (unless the reporter is the individual) will be redacted prior to receiving the information. Incident Data Trends Analysis/Risk Mitigation activities: The County Program Specialist/Risk Manager will compile data for trend analysis reviews of all incidents (including restraint and medication errors to include initiated reports that have not been submitted) reported at least semi-annually to identify risks that require intervention to avoid a crisis via the Risk Management Team meeting. Assistance will be provided by the team to mitigate all situations identified as potential risks to the health and welfare of individuals to the SCO and provider by the County Program Specialist/Risk Manager. In addition, the trend analysis shall include, but is not limited to:  The review of all restraint and medication error EIM incident reports on a periodic basis.  An analysis of compliance with timeframes in accordance with the IM bulletin for reporting, investigation and finalization of incidents.  This process is also to include the review of reports that have been initiated but not submitted.  Evaluation of the circumstances and frequency of restraints and medication errors on a periodic basis, including the use of the restraint dashboard.  Methods to recognize unreported critical incidents and ensure reporting, investigation and implementation of corrective actions.  Collaboration and communication with the individual’s team to ensure health and safety.  Collaboration and communication with the individual’s team to revise ISP, behavior support plan, and risk mitigation plan.  Collaboration with the waiver individual and their team to develop mitigation plans.  Ensuring that these activities are not delegated to a SCO or other entity. HUMAN RIGHTS COMMITTEE (HRC) MH/IDD/EI will safeguard the human rights of people receiving services and supports by: 5  Ensuring the use of restraints and restrictive interventions are appropriate and necessary via the quarterly Risk Management meetings review of incidents and restrictive procedures (random sample, min of 10% annually).  Ensuring that strategies and positive interventions exist to reduce and/or eliminate the need for of restraints and restrictive procedures through systemic review and technical assistance.  Risk Management team/HRC will include representation from the SCO and Health Care Quality Unit.  A data spreadsheet will be maintained that includes; demographic information, type of restrictive intervention, date of implementation, period of review, explanation of need, and committee recommendations.  Each Provider must establish a Human Rights Team within their agency to approve the implementation of allowable restrictive procedures. The County Human Rights Committee will not act in the capacity of the Human Rights Team for provider agencies. Training:  Training will be provided ongoing to individuals, families, guardians, and advocates regarding their rights, roles, and responsibilities upon intake and as needed.  Formal training will be offered to all providers by the Program Specialist/County Incident Manager. Ongoing support and training will also be provided on responding to, documenting, preventing incidents including the use of restraints and restrictive procedures and human rights.