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Incident Management Bulletin

Introduction Webinar

Course #: ID-2021-01

March/April 2021

Hello. My name is Bill Posavec. I am a Section Chief in the Division of Program Operation in ODP’s Bureau of Community Services. Hi, this is Katie‐Marie Wilson, policy supervisor from ODP’s Bureau of Policy and Quality Management. We are the presenters for today’s webinar that introduces the Incident Management Bulletin. The Bulletin was issued on March 1, 2021 and will be effective on July 1, 2021. Going forward in this webinar we will use IM as the abbreviation for incident management.

Today’s session is being recorded. The recording and the PowerPoint presentation with full trainer notes will be posted to the MyODP website after the last webinar.

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Incident Management Bulletin: Introduction Webinar


Deputy Secretary Kristin Ahrens

Office of Developmental Programs

Welcome

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We will begin today’s webinar with a video message from ODP Deputy Secretary Kristin Ahrens. If you need to adjust your speaker volume to hear the video, please do so now.

Hi ‐ I’m Kristin Ahrens. I’m the Deputy Secretary for the Office of Developmental

Programs within Pennsylvania’s Department of Human Services, and I am here to

welcome you to the Introduction to the Incident Management Bulletin.

This webinar is part of a larger series of webinars and webcasts on ODP's Incident

Management System. This session should help you identify and understand your very

critical role in keeping people healthy and safe… and I don't just mean the people that

you directly support, but any individual with an intellectual disability or autism who you

may discover or recognize is at risk of harm.

In this session you are going to hear directly from self‐advocates and families about how

important they feel the incident management system is. You will also hear real stories

about hurt and harm that have come to the people that we support, and I am going to

urge you now to take care of yourselves during this session. If these stories trigger

memories for you, and remind you of experiences that you had, and you need to take a

break, please do that. Please take the course at your own pace, reach out to your

supervisor, your agency if you need some additional support.

Every one of us, from the CEO, to the direct support professional, to the bookkeeper, the

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van driver, the program specialist, every one of us has the same responsibility in the

system, and that is to protect individuals with intellectual disabilities and autism. It’s to

protect people from harm. Incident management is not just about immediately

responding to something that’s happened, but it's about understanding why that thing

happened, why that person experienced harm or hurt, and then taking the steps to make

sure that doesn’t happen in the future.

One of the things that all of us in this profession need to understand is that at some point

it is very likely that we will be the target of an investigation. That doesn’t mean that

necessarily we did anything wrong. What that means is when bad things happen to

people, we need to understand why, so that we can take steps to prevent it in the future.

Incident management is about quality improvement. It's about building communities we

want. It’s about building safe places to live and work and spend time with people. It's

about creating a culture of safety… where… that’s rooted in open communication. It’s

rooted in transparency, and definitely rooted in the deep appreciation of the work that

direct support professionals do every day.

The theme of the Incident Management Training series is ‐ Respect, Listen, Ask, Believe

and Respond. First and foremost, the theme relates to individuals we support, but it also

relates to our coworkers, the people we supervise, and our employees. Everyone should

be encouraged and supported to speak up to protect the health and safety of the

individuals that we support.

To summarize all this, incident management is critically important because every incident

directly ties back to an individual. So, it ties back to an individual that may have been

harmed or hurt, and our actions in recognizing, reporting and responding to those

incidents are ultimately what will keep people healthy and safe.

So ‐ thank you for everything that you do on behalf of the individuals that we are here to

support. We appreciate everything you do to help people live everyday lives. Thank you.

Thanks to Deputy Secretary Ahrens for sharing her thoughts on why incident management is important to you and individuals with an Intellectual Disability or Autism.


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Training Plan (March – July 2021)

Topic Method Target Date

Introduction to IM Webinar March/April 2021

Overview of IM Webinar April 2021

Recognizing Incidents

9-part Webcast Series April 2021

Responding to Incidents

Webcast Series and Family Resource

June 2021

Training for Families

Webinar or Webcast, and Family Resource

July 2021

Today’s webinar is scheduled for 90 minutes and we will have time at the end to respond to some frequently asked questions.

This webinar is the first of many hours of training content that will be provided by ODP and shown in this training plan on the screen. We recognize that you are eager to have all your questions answered but the number of participants makes that impossible for today. Remember that the implementation date is July 1st. We anticipate that many of your questions will be answered in today’s webinar and in subsequent training. In addition to training, ODP will be available to provide support to assist with preparation and successful implementation over the next months.

We ask that you submit comments and questions at any time during the presentation through the Question Pane in your control panel. All questions will be reported to us for review to get an overall sense of questions, major concerns and need for follow up. As I said, we will answer some frequently asked written questions before we end today’s webinar.

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Introduction

Incident Management Bulletin #: 00-21-02

Issue date: March 1, 2021

Effective date: July 1, 2021

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ODP training on the IM Bulletin will take place over the next several years with the goal of ensuring standardization of knowledge, concepts, and operational practices related to ODP’s incident management processes. This is an interpretation of the regulations and how the practices will be used. The information provided is important to everyone who supports Individuals with an Intellectual Disability or Autism including Providers, SCOs, County ID Programs/AEs, and Family Members.

Throughout the presentation, when we refer to an individual, we are talking about an individual with an Intellectual Disability or Autism.

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Introduction

Training meets the General Orientation and Annual Training requirements

specific to recognizing and reporting incidents as

identified in the 55 PA Code Chapters 6100, 6400, 6500,

2380 and 2390 Regulations.

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The content of the Incident Management training series is offered by the Office of Developmental Programs to meet the General Orientation and Annual Training requirements specific to recognizing and reporting incidents. The requirements are identified in 55 PA Code Chapters 6100 (All Services), 6400 (Community Homes), 6500 (Life Sharing), 2380 (Adult Training Facility) and 2390 (Vocational Training) regulations. See the Incident Management Bulletin Training Requirements Flow Chartposted on the MyODP course page for specific information related to fulfilling the General Orientation and Annual Training requirements.

The content of the training series is a companion, not a substitute, for reading the Incident Management Bulletin to ensure your full understanding and ability to implement the required practices. In general, organizational leadership will need to read the entire Bulletin and then develop and implement the written agency policies and procedures to ensure their staff are able to carry out their roles and responsibilities.

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Certificates of Achievement

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You will need to login to your individual account on the MyODP website and navigate to the Incident Management Bulletin course to receive a certificate for participating in the live webinar or viewing the recording of this presentation.

Individual Certificates of Achievement will be available to all professional staff including Direct Care Provider Agencies and Supports Coordination Organizations after completing the required Training Confirmation for this webinar. After participating in the webinar today, you will need to complete the Training Confirmation on the MyODP website before May 15, 2021 in order to have access to your certificate. Please view and then save or print your certificate to receive credit for this webinar.

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Purpose

Describe and discuss the:

• training theme for the series and connection to Everyday Lives:

• history and background of why the Bulletin has changed;

• development and research behind the Bulletin;

• first few sections of the Bulletin;

• major takeaways; and

• multi-year training plan.

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In this Introduction to the IM Bulletin, we will describe and discuss the:• training theme for the series and connection to Everyday Lives;• some history and background of why the Bulletin has changed;• our development and research process;• the first few sections of the Bulletin; • some major takeaways; and• the multi‐year training plan.

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Everyday Lives

What is important to you?

Self-determination

Important to families

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Everyday Lives is at the foundation of the IM system. Everyday Lives are the principles and values that guide all services and supports provided to our fellow Pennsylvanians.

Started back in 1989, ODP invited people with developmental disabilities, families, advocates, government officials, and service providers to think about what the future should look like for all people with disabilities. For the first time, people with developmental disabilities were asked directly – what is important to you?

Everyday Lives is rooted in the values of self‐determination promoting the belief that with the support of family and friends, people with developmental disabilities can and should decide how to live their lives.

In 2016, Everyday Lives: Values in Action was published and reaffirms and updates what is important to people with developmental disabilities and includes the values that are important to families.

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I am healthy and safe in all areas of my life. I, my family, supporters and community balance health, safety and risk according to my

needs and wants.

I have the same rights as all other members of the community and I can fully use them. My family, supporters and community respect my rights.

Everyday Lives Value Statements

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Here are two value statements expressed by individuals in Everyday Lives.

• I have the same rights as all other members of the community, and I can fully use them. My family, supporters and community respect my rights.

• I am healthy and safe in all areas of my life. I, my family, supporters and community balance health, safety and risk according to my needs and wants.

Rights, health and safety are the focus of these statements. The same focus that is at the core of Incident Management.

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Everyday Lives Recommendation

Recommendation 5: Promote Health, Wellness and Safety

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Everyday Lives: Values in Action includes recommendations, strategies, and performance measures to guide ODP and gauge its progress in achieving the important goals put forth in Everyday Lives.

The activities and outcomes of Incident Management is one measure to determine the progress for Recommendation #5 – to promote health, wellness and safety.

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Theme

Respect

Listen

Ask

Believe

Respond

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Unfortunately, we know that there are unsafe and unhealthy things that happen to individuals that we support. The events range from mild to severe and shocking and put people in harm’s way. Some events have the potential to cause lifelong trauma. So, how do we act and address this reality in a way that demonstrates our understanding of the issues, promotes health and safety, and minimizes potential trauma?

Our answer is in this theme that emerged during the development of the Bulletin and this training series ‐ Respect, Listen, Ask, Believe and Respond.

Let’s look at each one of the theme’s components.

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Theme

Respect

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Respect is shown through words and actions that tells the individual that you accept what is being said or seen. Acceptance is judgement‐free with no evaluation of facts or fiction.

Being respectful is not dismissing what happens or what is said because of experience or reputation. Not listening to someone because he is seen as a trouble‐maker or someone who makes up stories places the person at greater risk for harm. Respect means taking the individual and situation seriously every time and saying thank you for trusting me.

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Theme

Respect

Listen

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Individuals with ID/A communicate through words AND behavior. When we are listening to words, we are also listening to behavior to discover what more an individual is telling us. For an individual who does not communicate using words, their behavior may be the only way to tell us that something is wrong. We are responsible to learn how the person communicates whether through words or action.

But even if a person does communicate using words, they still may not be able to effectively communicate what has happened. We need to listen fully in order to understand what the individual is telling us in order to protect their health and safety.

Provider, SCO and County ID Program/AE management needs to listen to individuals, families, and staff when told about situations and events that are happening in their agency. When management demonstrates that they are listening, individuals, families, and staff will be more willing to talk. Individuals will be safer and healthier when everyone is listening.

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Theme

Respect

Listen

Ask

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It can be very difficult to talk about something bad that has happened to you or something that you have seen happen to someone else.

When you are being told about something harmful that happened to someone, your first reaction may be to ask questions. That’s natural and we do need to ask questions to find out how we can help. Ask the individual to tell you anything they can remember. Asking how you can help or what the individual needs are good first questions to ask. Remember though, this is not an informal mini‐investigation. You are asking questions only to support the individual who has been hurt or harmed.

You should avoid asking specific, leading questions. Specific questions such as who, what, where, and when can make a victim feel like a failure if they cannot provide a response. Victims may also think that you do not believe them if they can’t answer all the specific questions that they are asked. One thing you should never do is ask the victim “WHY” they believe the abuse or harm has occurred. This may make the victim feel that they are to blame.

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Theme

Respect

Listen

Ask

Believe

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The theme is building now on the former key points. Showing respect, fully listening, and asking helpful questions tells the person that you believe what has happened. It takes so much for someone to tell you about something harmful that has happened. But if not believed, we are setting up people to be hurt or harmed again and again.

If someone tells you something has happened that is hurtful or harmful, act to help the person be safe to prevent harm from happening again.

While in the moment you may want to say things to give the person an increased sense of safety, be careful not to:• make promises you can’t keep or• promise absolute safety from further abuse

Believing an individual brings with it the trust that what is said will be taken seriously. Without first believing the individual, the IM process of discovery does not begin, and you cannot protect individuals from harm.

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Ramon

Believe

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I have been talking about believing the individual, but this idea needs to be expanded to include the Direct Support Professional. Staff are the eyes and ears of the provider agency, the family and the Office of Developmental Programs (ODP). We need to believe what a staff person tells us when they see something is different, odd, or unusual.

Here’s an example. Like all the stories we will use in this training series, examples are real and happened to an individual with ID/A in Pennsylvania.

Ramon always wore top of the line clothes. He wore nothing but high‐end brand names with form fitted caps to the latest Jordan’s. He never went out of the house without matching all his clothes, his fitted hat or his Jordan’s.

One time he came home from a weekend with a paid respite provider, and he was wearing a plain black cap. Instead of Jordan’s he was wearing New Balance sneakers and his clothes were wrinkled and not freshly pressed like usual.

Mike, his DSP saw this, and something seemed odd. He asked himself – why is he wearing that hat and sneakers? That is not how Ramon usually dresses and likes to look. Equally important, Mike told his supervisor that something seemed different. The supervisor believed him and took action to follow up.

Later, it was found out that Ramon’s clothing had been intentionally switched out. The quality of the clothing switch was not the same and Ramon came away with less than what he had before the visit.

Mike followed his instincts, told his supervisor and was believed. As a result, Ramon was protected from possible future exploitation and theft.

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Theme

Respect

Listen

Ask

Believe

Respond

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The last key point of the theme is to respond. You must respond to the situation by taking immediate action to protect the individual's health, safety, and rights.

The first action in response is to take action to protect the person from further harm.

For example, you may need to call 911 or the police, or you may need to apply first aid, depending on the situation. As we said earlier, do not assume something did or didn’t happen due to your own pre‐conceived notions. You must report what the individual explained to you leaving out your opinion or thoughts on the situation.

After you report the situation, if you know any next steps the individual may take, you can inform the individual of those steps. However, if you don’t know the next steps, simply tell the individual that you or someone from the agency will let them know what to expect next ‐ when that information is known.

As a supporter, your honest and genuine expression of care and concern for the individual is so important when you are responding.

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IM Bulletin Changes - Regulations

RespectListenAskBelieveRespond

Regulations identify what are the IM requirements.

IM Bulletin describes how the system works.

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With our theme and Everyday Lives as the foundation, let’s turn now to the history and background of the new IM Bulletin. Why has the IM Bulletin changed?

The current IM Bulletin has been in place since 2004. A great deal has changed in the

past 16 years, practices have evolved.

Recent big changes include new program regulations and revised licensing regulations.

The Chapter 6100 Regulations were put in place in October 2019 and are very closely

aligned with Chapters 6400, 6500, 2380 and 2390 Regulations.

The IM Bulletin provides the detailed clarification of incident management requirements

outlined in the Chapter 6100 Regulations. The 6100 Regulations intentionally have

limited detail; how you implement the requirements of the Regulations is described in

the IM Bulletin. In other words, the Chapter 6100 Regulations identify what are the

requirements, the IM Bulletin describes how the system is to work.

A simple example is ‐ the Chapter 6100 Regulations state that you must report, the IM

Bulletin describes how you report incidents.

A link to the 6100 Regulations is available as a resource to this training.

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Abuse is in part hindered because “policies and procedures did not establish clear definitions and examples of potential abuse or neglect that should be reported.”

IM Bulletin Changes - OIG

(MA OIG Report July 2016 A‐01‐14‐00008)

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Another driver for changing the IM Bulletin is the Office of the Inspector General (OIG) in

the U.S Department of Health and Human Services. The OIG is a state audit of

compliance to federal waiver requirements and identifies promising practices.

Looking across states, the OIG recognized that abuse is in part hindered because

“policies and procedures did not establish clear definitions and examples of potential

abuse or neglect that should be reported”.

While the OIG report focuses on Abuse and Neglect, the IM Bulletin provides definitions

for all primary and secondary categories.

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ODP Subject Matter Experts

IM Bulletin Development

Incident Management Reports

Stakeholder Contribution

Listening Tours and Public Comment Process

Research and Industry Standards

National Best Practice

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Development of the current IM Bulletin began in 2014 and included subject matter experts from across ODP bureaus and offices.

Stakeholder contribution to the Bulletin content was received in several different ways.

Every time you report or manage an incident you are giving ODP information to be used in procedure/practice development. ODP reads and reviews all incidents that are reported in the Enterprise Incident Management system (EIM) . Information that you write into an incident report is discussed and analyzed to identify system‐wide policy and technology solutions to improve the IM process.

In addition to stakeholder contribution based on reporting, the Bulletin reflects discussion from statewide listening tours and the public comment process.

Lastly, practices and requirements identified in the Bulletin are based on research, industry standards and nationally recognized best practices.

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Incident Management

Risk Management

Quality Management

IM Bulletin - Scope and Purpose

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See pages 1 - 2 in the IM Bulletin

Now I am going to briefly review the first sections of the Bulletin, so you are familiar with the structure and content. In depth information on the specific requirements and definitions contained in the Bulletin will be provided in future training.

The Bulletin begins with a statement of scope identifying all the individuals, agencies, providers, services, programs and waivers that are covered by this Bulletin.

The purpose of the Bulletin is to specify the operating procedures, requirements and uniform practices of the incident management process. In the Purpose section, incident management is connected to the larger risk management and quality management processes that rely on collaboration between many different people and organizations.

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• Build policies and structures to support IM.

• Provide a timely and appropriate response to incidents.

• Report, investigate and take correction action in response to incidents.

• Implement quality management, risk management and incident management processes.

IM Bulletin – Required Practices

To Keep People Safe:

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See pages 1 - 2 in the IM Bulletin

The incident management processes in this Bulletin include uniform practices for:

• building policies and structures to support IM;

• timely and appropriate response to incidents;

• reporting, investigating and taking corrective action in response to incidents;

and

• implementing quality management, risk management and incident

management processes.

The practice of Incident Management identified in the Bulletin is to lead local, agency‐wide and systemic improvement to strengthen the overall provider network so that services rendered to Pennsylvanians are of the highest quality.

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Primary Goal of IM System

IM Bulletin - Background

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To ensure that when an incident occurs or is suspected or alleged to have occurred, the response to the incident protects and promotes the health, safety, and rights of the individual.

The next section of the IM Bulletin is Background which identifies the primary goal of the IM system ‐ to ensure that when an incident occurs or is suspected or alleged to haveoccurred, the response to the incident protects and promotes the health, safety, andrights of the individual.


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Incident Management Saves Lives

Recognizing and reporting are critical to prevent reoccurrence.

IM Bulletin - Discussion

Conduct agency wide analysis of incidents to promote system-wide changes for quality improvement.

Meaningful corrective actions prevent harmful things from happening again.

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See page 2 in the IM Bulletin

In the Discussion section of the Bulletin, it is identified that incident management begins

with recognition, reporting and response. Recognizing and reporting are critical so that

the same thing does not happen to the same person or anyone else. Developing

meaningful corrective actions prevent harmful things from happening again to the

individuals you support.

And it is worth repeating – without recognition there is no IM process. You must look

for it, notice it and tell someone when something hurtful or harmful is happening to an

individual you support.

Incident management emphasizes agency wide analysis of incidents to implement

processes that promote system‐wide changes for quality improvement. Recognizing and

reporting incidents are critical because incident management saves lives.

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“Any person, including the victim, who reports an incident or cooperates with an investigation should be free from intimidation and discriminatory, retaliatory, or disciplinary actions.”

IM Bulletin – Discussion

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“Individuals who report an incident or cooperate with an investigation have rights under the Whistleblower Law (43 P.S. §§ 1421–1428) and the Older Adults Protective Services Act (35 P.S. §§ 10225.101–10225.5102).”

A critical component of the ODP Incident Management system is the protections for people who recognize and report. The Bulletin states that “any person, including the victim, who reports an incident or cooperates with an investigation should be free from intimidation and discriminatory, retaliatory, or disciplinary actions.”

To be sure these protections are understood and in place, the Discussion section of the Bulletin, identifies the protection rights under the Whistleblower Law and the Older Adults Protective Services Act.


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IM Bulletin - Discussion

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Incident management is based on a risk mitigation strategy that is person‐centered. The goal of person‐centered thinking is to understand what each individual person wants and needs to live their own, personally defined good life. This includes understanding what is Important TO (what matters to the person) and What is Important FOR the person (to help ensure health and safety and to be valued in the community) and then finding ways to help the person to achieve a balance. Risk mitigation uses data and information about each person's abilities and needs to evaluate and implement actions to eliminate or reduce recurrence of bad things happening to individuals.

There are excellent training resources on the MyODP website to help you to understand and implement risk mitigation that balances health and safety with acceptable levels of risk that supports opportunities for adventure, new friends, fun and self‐esteem. Links to these resources are in the course where you accessed this webinar.

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Educate and Inform Individuals and Families

Major Takeaways

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Meet the person’s communication needs

In this next part of the webinar, I will introduce major takeaways, the big picture ideas of what you will notice when you read the Bulletin. As I’ve said before, details and examples will be provided in future webinars and webcasts; this is just an introduction.

The IM Bulletin emphasizes the involvement of individuals with an Intellectual Disability or Autism, families and designees in the IM process as much as possible. Everyone who has a role in Incident Management should ensure that individuals, families and persons designated by the individual are offered education and information about incident management policies and procedures. Education and information should be presented in a format that meets the person’s communication needs.

The Chapter 6100 Regulations specifically state the requirement to educate individuals about the circumstances of the incidents and corrective action. How you do that is determined by your agency local practice. Providing the education and information is a requirement to fulfill regulation.

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Education and Training

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Here is an example. As a result of a hospitalization, Billy was diagnosed with Diabetes. To help Billy stay healthy and safe and to avoid future incidents, he will need his blood sugar monitored before each meal. His provider will need to ensure that Billy and his staff are trained to do the testing, make sure that the equipment works, that all needed supplies are available, and explain why it is needed for his health.

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Individuals and families can submit formal complaints about the IM process.

IM Service Complaints

Agencies are required to have a method to address IM complaints.

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The IM Bulletin directs agencies to put practices in place that ensure the individual is kept in the loop on everything related to an incident that happened to them. As we already mentioned, incident management is part of the service delivered to all individuals and therefore individuals and families have the right to submit formal complaints about the IM process.

This can include filing a complaint if they disagree with how an incident or investigation was managed. Agencies are required to have a method to accept and resolve IM complaints which must be explained to his or her family.

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Details and descriptions

Primary and Secondary Categories

Consistency

Focus on corrective actions

Better data analytics

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This is the next major takeaway from the IM Bulletin. Included in the Bulletin are definitions of every Primary and Secondary Category.

ODP previously provided some category definitions but now you will notice detail and description for all categories. Consistent use and implementation of the definitions with an increased focus on corrective action will promote better outcomes for individuals.

Greater details in the definitions will allow for better data analysis to identify the need for targeted training, technical assistance and statewide action.

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25,000 Hospitalizations and ER Visits – Why?

Hospitalization and ER visit is the response to the event.

Tell the Story – What Happened?

1,000 Serious Illnesses.

Tells you what happened.

Categories and definitions no longer include the person (target) that may have contributed to what happened.

Focus on what happened.

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Something that you will see when reading the Bulletin is that the definitions have changed from categorizing the response to an incident, to a description of what happened. Simply said, we want you to tell the story.

Let me give you an example. When EIM data identify that a total of 25,000 hospitalizations or ER visits occurred in 2019, all we know is that on 25,000 occasions people were admitted to the hospital or went to the ER. We are missing the critical piece of information about what happened that required the hospital admission or ER visit. On the other hand, if we report that there was a serious illness, we know just what happened. Through full reporting we will have data about where the individual went for care or treatment, like an ER or Urgent Care.

Another change is that categories and definitions no longer include the target or person who may have contributed to the incident, such as another individual recipient of service or staff person. This information is captured later so that the category can focus on what happened.

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Detect Incidents

Suspicions, allegations and actual occurrences

must be reported.

Use your instincts.

Tell someone.

You’re doing the right thing.

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The last big takeaway has implications for everyone’s role and responsibility in the Incident Management process.

We all need to commit to raising our awareness to actively detect incidents. In the Bulletin, suspicions, allegations and actual occurrences of harm are to be reported regardless of actual or perceived harm to the individual.

It is understandable that you may feel hesitant to report something that you just suspect, without being sure it happened. But you must always lean on the side of precaution and protect the individual you are providing service to, which could include using your instincts to recognize when something hurtful or harmful may be happening.

You do this all the time in your personal life to protect the people closest to you. You might talk about your radar, or Spidey Sense or a bad feeling about something. In our personal life we might tell someone or try to find out more before we act. But in this public service system, the role is distinct and clear. Use your instincts to tell you if something is wrong, hurtful or harmful AND tell someone about it immediately. You need to adopt the idea that when you tell someone, you have done something right.

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Encourage Everyone to Notice

Keeping individuals healthy and safe, and supporting everyone to recognize and report.

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Helping to keep individuals healthy and safe, and appreciating and supporting everyone to recognize and report is one of the long‐term goals of Incident Management.

We should thank people for recognizing and reporting incidents because we want to encourage everyone to notice and report to help individuals to be healthy and safe. Whether what you noticed was proven to occur or not, everyone should know that recognizing and reporting (not denying or ignoring) are what will help keep people healthy and safe, and it is required.

Staff who report an alleged incident should not fear retribution, payback, or punishment. They should be thanked for telling someone what they saw or suspected or discovered.

Tell the story through documentation. Explain the reason for what happened. Did you try to do what is best for the person? What was the intent of your actions? When County ID Programs/AEs and ODP do look backs/look behinds, they look for the documentation to show the good work and the reasonable actions that followed to prevent bad things from happening again.

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What Really Happened?

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Here’s an example.

Laura did not want to get out of bed to take her seizure medication in the morning. She was talking on her cell phone. Her DSP, Benjy, knocked on her door and reminded her that it was time to take her medicine. Laura kept talking and would not get out of bed. Benjy was kind and respectful in his words and tone reminding Laura several more times why it was important to take the medicine. She would not get out of bed.

Time was passing and it was already late for Laura to take her seizure medicine. Benjy took away Laura’s cell phone and told her that she would get it back as soon as she took her pills.

So, what really happened here?

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Learning Opportunity

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BENJY

• Worried about Laura.

• Worried about getting in trouble.

• Needed to do something.

LAURA AND HER TEAM

• Plan for variations in routine.

• Use technology.

• Balance Important To and Important For.

AGENCY• Individualized, person-centered

planning.• Staff training.• Balance level of risk with skills

and what is Important To the person.

Although Benjy acted with his best intentions, this created a learning opportunity for Benjy and Laura’s team.

First, Benjy was worried that if Laura did not take her medication on time, she would have a seizure. He was doing what he thought was best to protect Laura. He was also worried about getting in trouble if Laura did not take her medication at the exact time it was required. Benjy thought he needed to find a way to make sure she took her medication.

While developing and maintaining a routine is important to and important for Laura, Benjy and the team need to be mindful that changes in routine are part of an everyday life. Maybe you can relate to Laura if you take a morning medication at a usual time, but on the weekends perhaps you like to sleep in and take it later.

This incident identifies that there needs to be a plan that works for Laura to take her medication on time in the morning.

Benjy learned that Laura has the right to refuse taking her medication (as you and I do) and that Benjy should not have taken her cell phone away. Laura was educated on the importance of taking her medication on time and Benjy learned about other options that Laura was willing to try such as using an alarm as a reminder that it is time to take her medication. That will help Laura AND Benjy.

What happened to Laura should be recognized and reported as a Rights Violation and is a prime example of how something with the best intention, is considered an incident. This is an opportunity to look at staff training to better understand what happened and why. None of us would appreciate if someone took our personal property, even if it was meant to encourage us to do something that was needed to help us be healthy and safe.

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NOT CHANGED – IM Process and Workflow

No major changes to timeline or deadlines; management reviews; and most roles.

IM – Changed or Not Changed

CHANGED – Enterprise Incident Management (EIM)

Aligns with the revised primary and secondary categories on the Bulletin implementation date.

Separate targeted training will be provided.

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This next section of the webinar will highlight eight changes as well as processes and

practices that have not changed.

Most of the process and workflow of Incident Management has not changed. There are

no major changes to timeline or deadlines; management reviews; and most roles. Some

of these practices may be newly included in this 2021 Bulletin but were already being

done.

Enterprise Incident Management (EIM) has changed to align with the revised primary

and secondary categories on the effective date of the Bulletin. Separate EIM training will

be provided and announced through ODP Communications when available.

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Reminder: categories define what happened; not the

response.

IM – Changed

CHANGED – Emergency Room Visits for Illness

An ER visit for illness will only get reported if the illness became serious enough to require a hospitalization.

This type of event is now reported under Serious Illness.

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In the Bulletin, there is no required reporting of emergency room visits for illness. An ER visit for illness will only get reported if the illness became serious enough to require a hospitalization.

This type of event is now reported under Serious Illness. Remember that the categories define what happened; not the response.

For example, Carla is sick, but you cannot get an appointment with her Primary Care Physician (PCP). The PCP office instructs you to go to the emergency room where they determine that she has a stomach virus, gives her a prescription for medication, and sends her home.

So, an ER visit as described in this example about Carla, does not qualify as an incident because she was not admitted to the hospital.

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CHANGED – County ID Programs/AE Incident Manager

County ID Program/IM Manager is required to be a Certified Investigator with certification in place within 12 months of assuming the manager role.

Specific categories now require an AE investigation to identify and follow up on agency-wide practice.

IM – Changed

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There are two changes specific to the County ID Programs/AEs to highlight.

The County Incident Manager is required to be a certified investigator. Certification must be in place within 12 months of assuming the manager role.

In addition, there are specific categories that now require an AE investigation because the secondary category may be associated with an agency‐wide issue.

For example, through a reported incident for one individual, an agency over‐charging for room and board cost was found. There is a chance that if a provider is charging more than what is allowed for room and board for one person they serve, there could be additional individuals at the organization that are also being over‐charged. County and AE programs should be expanding investigations to detect agency‐wide issues.

This is an example about how investigating an incident for one individual and implementing corrective actions can be preventative for all individuals served.

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IM – Changed

CHANGED – Bureau of Supports for Autism and Special Populations (BSASP)

IM Bulletin is new for BSASP-only providers.

IM framework already implemented for individuals in the Autism Waiver for certain identified requirements.

Provider Support Mailbox: [email protected]

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In preparing this training, ODP recognized that the implementation of the IM Bulletin is new for the Bureau of Supports for Autism and Special Populations (BSASP) providers.

The IM Bulletin framework has already been implemented for individuals in the Adult Autism Waiver with pieces and parts identified as requirements.

Now all ODP services provided to ID/A and Autism are the same and that includes the full implementation of the IM Bulletin for individuals receiving support from BSASP. There is additional clarification provided in the Bulletin specific to BSASP, like the difference in the Administrative Entity role and function.

BSASP providers are encouraged to email the Provider Support mailbox for targeted assistance as needed.

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IM – Changed

Abuse, neglect, exploitation and rights violation (critical incident categories) have been moved up in the hierarchy of importance.

CHANGED – Primary and Secondary Categories

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Sexual abuse is now a separate primary category.

Self-neglect and passive neglect are new primary categories managed by the SCO; no paid caregiver involvement.

As we previously said, the definitions for primary and secondary categories have been

expanded to provide greater detail. In addition, abuse, neglect, exploitation and rights

violation (critical incident categories) have been moved up in the sequence of reporting.

Sexual Abuse is now a separate Primary Category. This change is a direct result of the

recommendation from self‐advocate members of the Provider Oversight Sub‐Committee

of the statewide Information Sharing and Advisory Committee.

There are two new Primary Categories ‐ Self‐Neglect and Passive Neglect. According to

the definition, these new categories are managed just by the SCO because there is no

paid caregiver involved in this type of incident. Passive and Self‐Neglect incident

definitions align with protective service laws that do not require investigations when the

circumstances of the event are beyond the control of the individual or unpaid caregiver.

Actions resulting from this type of incident allow for the development of risk mitigation

strategies that include education and a connection to other entities that may be able to

assist and hopefully eliminate reoccurrence or future risk.

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IM Changed

PUBLIC HEALTH EMERGENCY - an event such as a disease or natural disaster that causes, or has the potential to cause, harm to a significant number of individuals and is officially declared as such by federal or state officials.

Public Health Emergency is a new Primary Category. It encompasses diseases, natural disasters, and attacks that cause harm or potential harm to a significant number of individuals. Public Health Emergencies are declared by federal or state officials. ODP will provide separate guidance on what to report related to Public Health Emergency.

In addition, there is a new Declared Emergency Primary Category. This is an event, such as an occurrence of a natural catastrophe, technological accident, or human‐caused event that has resulted in, or could potentially cause, severe property damage, death, and/or multiple injuries. A Declared Emergency is declared by Federal, State, County, or Municipal officials.


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IM – Changed

CHANGED – Increase in Investigations

Ability and encouragement to suspect, detect and recognize incidents.

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Chapter 6100 Regulations identify specific incidents that must be investigated.

If a person is physically hurt, there will be an investigation.

More injuries will be investigated.

The last change to note is that ODP anticipates that there will be a significant increase in the number of investigations to protect health, safety and rights. There are several reasons for the anticipated increase.

• Enhanced category definitions will increase ability and encouragement to suspect, detect and recognize incidents.

• The Chapter 6100 Regulations identify specific incidents that must be investigated. • If a person is physically injured by another individual who is also receiving service,

there will be an investigation. It does not matter who caused the injury to the individual; all events will be investigated. In the previous Bulletin, an investigation occurred only if what happened was sexual in nature by another individual who was receiving service.

• More injuries will be investigated. That is a change from 2018 when only approximately 13% of injuries were investigated in IM.

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Training will be provided to all stakeholders –Individuals, Families, County ID Programs/AE,

Providers, SCOs and ODP.

Train the Trainer

IM Training Plan

Webcasts

In-person

Webinars

Virtual Office Hours

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From this Introduction, you can see that there is a great deal to learn in order to ensure high quality incident management that is consistent across the Commonwealth.

Today’s webinar is the first training offered as part of a multi‐year training plan that includes a variety of methods. Training will be provided to all stakeholders – Individuals, Families, County ID Programs/AE, Providers, SCOs and ODP.

Training begins with delivery of information and over time moves to more in‐depth sessions with opportunities to practice, refine implementation strategies and address challenges identified in the field.

Training methods may include:• Webinars • Webcasts • In‐person • Train the Trainer • Virtual Office Hours and Technical Assistance

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IM Training (March – July 2021)

Topic Method Target Date

Introduction to IM Webinar March/April 2021

Overview of IM Webinar April 2021

Recognizing Incidents

9-part Webcast Series April 2021

Responding to Incidents

Webcast Series and Family Resource

June 2021

Training for Families

Webinar or Webcast, and Family Resource

July 2021

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On November 12, 2020 ODP issued Announcement #20‐107 which provided a timeline of key activities related to Incident Management. Included in this announcement was the target rollout for future IM Bulletin training. This information has been updated since the original distribution.

The next training identified in the timeline is the Overview of Incident Management webinar that provides a first‐look at definitions of primary categories. Several sessions of the webinar are offered in April 2021 and a recording of the presentation will be posted to the MyODP website.

Also, in April 2021, a 9‐part webcast series on Recognizing Incidents will be posted and available. You must participate in the Introduction and Overview webinars in order to view the Recognizing Incidents webcast series. You must view the webcast series in sequence.

IM training will continue in June 2021 with a Responding to Incidents webcast series that will include a resource for families. ODP is also planning to provide training to families in July 2021

All training will be announced through ODP Communications. Training target timelines and topics may change based on emerging needs and stakeholder feedback.

Remember there is the Incident Management Bulletin Training Requirements Flow Chart posted on the course page for specific information related to fulfilling General Orientation and Annual Training requirements.

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>www.dpw.state.pa.us >www.dhs.pa.gov 45

Thank you for participating in today’s webinar. The recording of the session and presentation with notes will be posted to the MyODP website and announced through ODP Communications.

To receive a certificate for today’s webinar, you will need to login to your individual account on the MyODP website and navigate to the Incident Management Bulletin course.

Individual Certificates of Achievement are available to all professional staff including Direct Care Provider Agencies and Supports Coordination Organizations after completing the required Training Confirmation. You will need to complete the Training Confirmation on the MyODP website before May 15, 2021 in order to access your certificate. Please view and then save or print your certificate to receive credit for this webinar.

Immediately following the webinar, you will see a pop‐up to complete a training evaluation. Please take a moment to complete the evaluation to provide your feedback on today’s training.

Thanks again and have a good day.

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Documents

Incident Management Bulletin - Amazon Web Services