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(CIRS)

Linda MetzgerColorado Department of Health Care, Policy & Financing

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mWhat Is a Critical Incident?

• 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.

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mApplicable Waiver Programs

• 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)

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m Why does the State need to track

Critical Incidents?• 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

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m Critical Incidents and the Department’s Quality Improvement Strategy

Monitoring Critical Incidents is a part of the Department’s Global Quality Improvement Strategy encompassing three functions:

• Discovery

• Remediation (Follow-Up)

• Continuous Improvement

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mProviders of Waiver Services

• 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

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mNumber of Critical Incidents

Reported per Month

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

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mReporting Issues

• 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

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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?

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mProvider Reporting

Forms

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

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mTypes of Critical Incidents to

Report

• Death• Suspected

Abuse/Neglect/Exploitation• Serious Illness• Injury to Client• Damage to Client’s Property or

Theft• Medication Management• Other High Risk Issues

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mDeath Types

• Ongoing Medical Condition/Illness/Disease

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

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mSuspected Abuse, Neglect or

Exploitation

• 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.

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mSerious Illness/Medical

Crisis

• Recurring Illness

• Heart attack (MI)

• Stroke (CVA)

• Pneumonia

• Respiratory failure

• Seizure

• Infection (UTI)

• Dehydration

• Cancer

• Diabetic Crisis

• Mental Illness symptoms

• Medical crisis

• Other illness

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Cause of Serious Illness

•New medical condition•Existing medical condition•Treatment error•Medication•Poor care•Undetermined•Other

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mSerious Injury

• Fracture/Dislocation

• Laceration• Serious Burn• Head Injury• Multiple injuries

• Unknown injury from fall requiring medical attention

• Unknown injury• Other injury

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mCause of Serious Injury

• Fall• Accident• Seizure• Assault

• Choking/Aspiration

• Physical Restraint

• Undetermined• Other

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mDamage to Client’s

Property/Theft

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

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mMedication Management

• 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

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mOther High Risk Issues

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.

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mTypes of 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

•Suicide ideation•Suicide attempt•Substance abuse•Media involvement•Environmental hazard•Restraints used

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1. Hospitalizations2. ER Visits3. Dr. Visits4. Law Enforcement Involvement

Common Reporting Items

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mUnnecessary or Inappropriate

Reporting Examples

•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

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mRecording a Critical Incident

Report

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

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mMandatory Reporting

Responsibilities

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

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mAfter a Critical Incident is

Reported

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

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mAfter 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

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mEntering a CIR in the BUS

After you login to the BUS, identify

the client for report entry

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mCIRS – Entering a Critical Incident

After you verified you have the

correct client, click on “Critical Incident Reports”

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mCIRS – Entering a CIR

You can click on “Add New CIRS” or “Add Critical

Incident” to start the entry process

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mCIRS – Entering the incident info

Make sure all

elements are

completed

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mCIRS – Incident Specific

Descriptors

Complete a thorough

description of the

incident circumstanc

esComplete

the incident specific

descriptors

Definition of what types of events

are appropria

te for each

incident type

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mCIRS – Persons Involved

After completing the incident descriptors,

click “Persons Involved”

Complete the sections for

name, relationship to client, and

role

Click “Add” to enter additional persons

involved

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mCIR – Mandatory Reports Made

Make sure all sections

are complete

After completing

Persons Involved, click on

Mandatory Reporting

Steps

Click “Add” to enter additional mandatory

reports made

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mCIRS – Follow Up Actions

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

welfareClick “Add” to enter additional follow up

actions

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mCIRS – Referrals Made

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

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mCIRS – Persons Notified

Click “Add” to enter additional persons

notified

After completing

Referral Steps, click on Persons

Notified

Complete all sections of the person

notified

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mCIRS – Post Report Follow-up

Provide narrative descriptio

n of additional informatio

n

Select Post Report

Follow-up to document additional incident related

information

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mHCBS Provider Reports to

SEP/CMA

• 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.

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QUESTIONS???