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HSD/MAD/QBCritical Incident Management Systemhttps://criticalincident.hsd.state.nm.us.

CENTENNIAL CARERevised November 1, 2013

.1INCIDENT 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.

2HSD/MAD/QAB Incident Management SystemThis presentation describes the statewide reporting requirements for incidents involving Home and Community Based Services recipients enrolled in Centennial Care -the new name for New Mexicos Medicaid Program.

3Why 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.

4Why 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.

5New Mexico Statutes/RegulationsIn 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.6Statutes and RegulationsAdult Protective Services - NMSA 1978, Section 27-7-30http://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 NMAChttp://dhi.health.state.nm.us/elibrary/regs/7.1.13NMAC_Incident_REP_INTAKE.pdf

7What Types of IncidentsAre 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.8Abuse 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].9

Abuse

In the reporting system abuse includes:Sexual (directed at the recipient)Physical (directed at the recipient)Verbal (directed at the recipient)Self InjurySexual 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 specifiedNot specifying the type will likely generate a call for more information.

AbuseExamples

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.

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

Abuse/Caregiver abuse

Caregiver abuse is important to report.Seriously impacts the delivery of servicesIsolates the consumerService coordinator/consultant must be notified.Description of abuse will be documented in the narrative section of the report.13Caregiver 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.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

NeglectIn the reporting system neglect includes:Insufficient staffingStaff not performing assigned tasksCare not being given by family or others who have agreed to provide supportSelf 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.

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 billsdo not purchase sufficient food and supplies do not arrange or transport to needed medical caredo not provide support as agreed in the personalized service plan for the recipient. (staying overnight, bathing after paid caregiver hours, preparing meals, etc.)Self NeglectExamples:

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.

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

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)

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. 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.

23Unexpected DeathsExamples:HomicideSuicideAccidentDeath unlikely to be attributed to diagnosis/condition Expected DeathsExamples:HospiceTerminal conditionsEnd stage renal diseaseMultiple strokes/heart attacksAdvanced age (more than 90 years old)Deaths occurring in a facility while in treatment for disease

HospiceIf 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.DeathsDeaths 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.DeathsThe 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.

Other Reportable Incidents (ORI) Include:

Emergency Services Law Enforcement Intervention Environmental HazardMissing

29Emergency 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)30Emergency ServicesExamples 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.

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.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.

33Law Enforcement

Examples:Police are called to the recipients 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.

Law Enforcement

NOTE:Law Enforcement involvement for a caregiver is NOT an a reportable incident.However, there may be a reportable incident ifThe 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.

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. 36Environmental HazardsExamples:A fire or flood has created a hazard in the home.Animals are out of control at the homeThreatening servicesCreating more waste that can be cleaned timely.Lack of repairs that create hazardsLack of water, electricity, heat that was in place previouslyWood heat or hauled water is not considered a hazard.Holes in the floorsRoofs that leakWindows and doors brokenDebris not cleared.Foul smells, piles of garbage, standing dirty water, etc..Clutter that impedes normal movement to bathrooms or exits.

Environmental HazardsExamples 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.Environmental HazardsThe 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.

MissingElopementPrimarily a Behavioral Health incident typeOccurs when someone is required to be somewhere and then leaves without permission or alerting othersWanderingUsed 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.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.

41Submitting an Incident ReportAgencies 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.

42Who 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.

43Self Directed ServicesIncident 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.

44Self Directed FMA is SpecialThe 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, etcThe FMA must share all the information they DO have.Name of MCO Accurate demographicsSS#Address, phone, etcDate of birthName and phone # of employee/caller

Behavioral Health Critical IncidentsBehavior 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.46Behavioral Health Critical IncidentsWhen a Behavioral Health (BH) provider opens a report to complete, the agencys name will self populate.The agency is recognized as a BH provider and two functions become enabled:A diagnoses dropdown boxA treatment location type drop down boxAlso one additional incident type becomes enabled.Behavioral Health Critical IncidentsDiagnoses Drop DownOnly a primary diagnoses will be selectedAll other diagnoses relevant to the report can be added to the free text diagnoses field.Treatment Site Drop DownThis 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.

Behavioral Health Critical IncidentsMany 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. Behavioral Health Critical IncidentsAn 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.

Reporting to Adult Protective Services

The MCOs report all incidents of Abuse, Neglect and Exploitation (ANE) which have been submitted to the HSD Critical Incident website to APS within 24 hours.If an agency directly reports a case to APS (and includes all required information) the agency will be able to get information about the report from APS. The agency is still required to report to the HSD Critical Incident Website.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.

If the recipient is under 18 years of age a report of Abuse, Neglect or Exploitation must be reported to Child Protective Services (CPS) Fax : 505.841.6691

52APS Reporting Requirements

Abuse, Neglect, Exploitation(ANE), And deaths suspected to be a result of ANE. Abuse, neglect, exploitation, deaths, emergency services, law enforcement involvement, and hazardous environments shall also be submitted to the HSD reporting website.Report all incidents within 24 hours!(Next business day in the event of weekend or holiday).53APS REPORTING GUIDELINESFirst and foremost, always ensure the safety of the recipient!

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.

54Deaths Reported to APSDeaths 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 do not need to be reported to APS. If the death occurs outside of a medical facility, local law enforcement must be notified. 55APS ProcedureAPS 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. 56Adult Protective Services Statewide Central Intake

Incidents involving suspected/alleged abuse, neglect, and exploitation must be referred immediately to:Telephone: 866.654.3219FAX: 505.476.4913

(The MCO for a Centennial Care recipient will report all ANE reports to APS within 24 hours of review of the online submission)

If the recipient is under 18 years of age a report of Abuse, Neglect or Exploitation must be reported toChild Protective Services (CPS) Fax : 505.841.6691

57Where Do We Send Incident Reports?

Centennial CareHSD/MAD/Quality Bureau:https://criticalincident.hsd.state.nm.us

APS Fax: 505-476-4913If the recipient is under 18 years of age a report of Abuse, Neglect or Exploitation must be reported toChild Protective Services (CPS) Fax : 505.841.6691

58Where Do We FAXother 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 Centennial Care the report ALSO goes to HSD/MAD/QB https://criticalincident.hsd.state.nm.us

Report incidents of abuse, neglect and exploitation of any individual outside of Medicaid programs to APS as mandated by state statute

59FraudAlleged Fraud is reported as follows:Follow the critical incident reporting process for all cases of Abuse, Neglect and Exploitation.Select Alleged Fraud check box within the form.Complete any MCO required reporting to the Managed Care Organization in which the recipient is enrolled.The MCO will review and investigate and report to the state the results of investigations.

FraudExamples of FraudThe consumer and the caregiver agree to sign off on timesheets that do not represent time worked.The caregiver has the consumer sign timesheets ahead of time and turns them in including time not worked.Billing is submitted when consumer is out of town or in the hospital.Consumer is selling Medicaid goods (Depends, DME or medications).Caregiver turns in timesheets for delivery of services to more than one consumer for the same time/date.

FraudNOTE:Examples of wrongdoing that are NOT fraud.These must be reported to the HSD Critical Incident website as exploitation but do not constitute fraud; the alleged fraud field will not be selected.The caregiver takes money from the consumers home.The consumer uses their Social Security check for drugs or gambling.The caregiver uses the consumers debit card for their own purchases.Consumer is intimidated into turning over the deed to their home.

HSD Incident Management System FAQ/Best PracticesWhat 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 recipients) 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 consumers service coordinator and guardian (if applicable) 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.

FAQ/Best PracticesWhat if the recipient does not have an MCO?

Select Not Medicaid Funding or Fee for Service (as appropriate) from the MCO drop down choices.For Native Americans who OPT OUT, use Fee for Service as a drop down choice. If Not Medicaid Funding is chosen, be prepared to answer questions from HSD. All Centennial Care recipients will select an MCO upon eligibility determination.

FAQ/Best PracticesCan I complete a report anonymously? If you are working for an agency, you must complete the report with your name and phone number and role with the agency.You may complete a report anonymously only if you are reporting as a private citizen who does not have a role in the services for the consumer.You may file a report based on an anonymous call.Anonymous reports are difficult to investigate and follow up and maybe screened out by the MCO and APS.FAQ/Best PracticesWhat do I do when a consumer calls in to report dangerous behavior?If a recipient calls and talks about hurting themselves or others you must have an appropriate and consistent response.Your agency must have a policy and procedure for addressing these kinds of calls. This policy must be shared with the recipient when they enroll in your agency and when you take the call about the concerning behavior.This policy will describe the options you will take which may include calling authorities or a counselor, redirecting to a crisis hot line or other interventions.The recipient should have a Care/Treatment plan that discusses what will occur when they share information about harm.The service coordinator must be immediately informed.

FAQ/Best PracticesWhy doesnt APS put the person into a nursing home?Why doesnt APS ever call me back?How do I know what APS found out?APS may be able to assist a vulnerable adult to get a guardian or may be able to do an emergency support situation. They can assist the courts to determine competency. They do not make permanent decisions about peoples lives.APS can tell a reporter of an incident if the report was received. They may have information including if the call was screened in or out. And if APS needs additional information or assistance with an investigation the reporting agency may be involved. APS has very strict procedure about sharing investigations and outcomes. APS will only do this if the reporters address and phone number is clearly written on the report.APS screens incident reports according to a strict criteria. A report that is screened out may be screened back in with additional information. A report that is screened out may be investigated or followed up by other parties; this is one reason reports are sent to different agencies.Managed Care OrganizationsMCOs are required to review and process all critical incidents submitted to the HSD web system for their enrollees within directed timeframes, including reporting ANE to APS.MCOs are required to submit all incidents they become aware of through their activities with the recipients.MCOs are required to train all staff who work with recipients directly or indirectly on the principals and practice of reporting incidents.MCOs are accountable for reviewing and establishing procedures for follow up including working with recipients, APS, local law enforcement, tribal social services and with the agencies that provide services.Managed Care OrganizationsMCOs are required to ensure that agencies who subcontract to provide authorized services are reporting incidents appropriately and collaborating with follow up activities. This includes documented training and technical assistance prior to any sanctions.MCOs are required to track and trend critical incident reports and report to the state as directed.MCOs report Critical Incident data and analysis to the State monthly and quarterly. This includes reports on the total Centennial Care population, on BH critical incidents and on incidents involving recipients of Self Directed Services.

Behavioral Health (BH) Critical IncidentsA report is considered a Behavioral Health Report when submitted by a BH provider for a client enrolled in Centennial Care.A Centennial Care recipient who has a behavioral health, mental health or substance abuse diagnosis whose incident is reported by other providers is NOT considered a BH incident and the report follows the process required in this training.BH Providers must report critical incidents as directed in this training.Behavioral Health Providers have additional information they must include in the reporting system such as selecting provider type. There are incident types that are critical to BH reports.Reports to the state by the MCOs for BH incidents require BH providers to include accurate Diagnoses codes..

Self Directed ServicesCritical Incidents involving recipients who are receiving Centennial Care Self Directed Services are reported following the direction in this training.Reporting an incident for this population requires that the Medicaid category of eligibility (COE) be selected and also that the Self Directed program be selected.This population will be increasing dramatically with Centennial Care and MCOs are required to track incidents for this population for monthly and quarterly reporting to the state.Reports for this population will be submitted by the agency that is providing the services, the consultant or broker for the recipient and by the Financial Management Agent (FMA currently XEROX) depending on who has information regarding the incident.

TIPS TO COMPLETING THE CRITICIAL INCIDENT REPORTBe accurate!Wrong information slows response to the issue and may violate HIPPA regulations.Have the correct information easily available to the reporter.Make sure the right people know about the incident!APS gets all Abuse, Neglect and Exploitation.These are reported by the MCO or HSD to APS from submitted reports. If you want APS to share any information with you, you must call in the report with your agency name and phone number. (See slide #38)Support Brokers and Service Coordinators need to know to help.TIPS TO COMPLETING THE CRITICIAL INCIDENT REPORTBe comprehensive!Make sure you have included the names and information needed to tell the story. The diary entries are available for more detailed information or updates.Be Brief!Just the facts, mam (or the allegations). Opinions and information not regarding the event slow down the responsiveness.Expect the call!Make sure your agency has all the back up information and documentation of any follow up activities done by the agency. Understand your responsibilities.

HSD/MAD/QB Contact Information

If you have questions about the website or thecontent of this presentation you may email HSD-QB-CIR@state.nm.us

You will receive a response to your questionswithin 48 hours.

Please allow additional time for weekends andholidays.

74~End~ Questions ?

HSD/MADQuality BureauNancy Haas, 505-476-7265 HSD-QB-CIR@state.nm.us Jeanne Cournoyer, 505-827-3109 HSD-QB-CIR@state.nm.us Amy Salazar, 505-827-3170 HSD-QB-CIR@state.nm.us