PA Dept. of Human Services, Office of Developmental ...€¦ · be entered into the enterprise incident management system within seventy‐two (72) hours of discovery/recognition

PA Dept. of Human Services, Office of Developmental Programs Provider Applicant Orientation Pre-Registration Module 4

Welcome to Pre‐Registration Module 4 of the Office of Developmental Programs’ Provider Applicant Orientation.

This module is the fourth in a series of modules to ensure that Applicants seeking to provide services to people with an Intellectual Disability [ID] and/or Autism Spectrum Disorder (ASD) obtain a basic understanding of how the Office of Developmental Programs (ODP) system works. The information in this module is about Incident and Risk Management and the responsibilities of providers and other stakeholders. It does not substitute for additional research using the resource materials available in this course.

This material is presented so that you may learn as much about how the system works as possible to prepare for attending an in‐person Provider Applicant Orientation session.

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This module is part of Step 1 shown on the slide. This is the third of six modules that must be completed before an Applicant can register for an in‐person session.

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Remember that only the CEO/Executive Director or an Independent Contractor should take the test that follows each module.

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Individuals have the right to Everyday Lives free of abuse, neglect, and exploitation. Providers are responsible to assure the health and safety of individuals you serve. While safe and accessible environments are everyone’s responsibility, those who work most closely with individuals receiving services and supports play an important role in identifying factors that increase risk to individuals by reporting incidents timely, completely, and accurately.

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Whenever you see the “Work in Progress” sign in this presentation, it indicates that there are upcoming changes.

The 6100 regulations will govern the program, operational and fiscal aspects of the following: (a) home and community‐based supports (HCBS) provided through the adult autism, consolidated and person/family directed support 1915(c) waiver programs; (b) Medicaid state plan HCBS for individuals with an intellectual disability or autism, such as targeted support management; and (c) services funded exclusively by grants to counties under the Mental Health and Intellectual Disability Act of 1966 or Article XIV‐B of the Human Services Code.

The 6100 regulations also amends four chapters of licensing regulations to eliminate duplication and conflict in the areas of training, rights, person‐centered support plans (PSP), incident management, positive intervention and medication administration. These licensing chapters are Chapters 2380, 2390, 6400 and 6500.

The 6100 regulations support Pennsylvanians with an intellectual disability or autism to live in and participate fully in the life of their community, to achieve greater independence and to have the full range of opportunities enjoyed by all citizens. The proposed rulemaking strengthens community supports to promote person‐centered approaches, community integration, personal choice, quality in support delivery, equity, and accountability in the utilization of resources and innovation in service design.

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ODP’s Incident Management Bulletin # 6000‐04‐01 Statement of Policy establishes standardized processes that ensure the health and safety, enhance the dignity and protect the rights of individuals who are registered with a county program or who receive supports and services from facilities licensed by DHS or Department of Health.

The processes include uniform practices for:

• Taking prompt and appropriate action in response to incidents.• Reporting of incidents.• Investigating incidents.• Taking corrective action in response to incidents.• Implementing quality improvement, risk management and incident management processes for the analysis and interpretation of individual and aggregate incident data.• Building organizational policies and structures to support incident management.

These policies and procedures are currently undergoing revision.

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The ODP Health Alert is intended to help providers and staff respond to medical emergencies by contacting 911 without delay. It is the policy of ODP that there should never be a delay in seeking emergency medical care. All provider staff must be trained in the ODP Health Alert and providers may not have policies that require staff to contact supervisors before calling 911 as this jeopardizes the health and welfare of the individual.

There are two key issues in reducing this risk for delay: 1. Recognizing a medical emergency ‐ because correctly interpreting and acting on

these signs could potentially save a life. 2. Seeking immediate attention for the emergency. With medical emergencies, time

is of the essence, and delays in treatment can often lead to more serious consequences, or even death..

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This Health Alert is intended to make all providers, staff, and other caregivers aware of this serious issue of choking. All should become familiar with resources to aid in the identification of individuals at risk for choking, the training of staff and the appropriate documentation of special dietary needs and choking precautions.

Two key issues to promote safety for individuals: 1. The information contained in the participants’ care plans, including medical

evaluations/recommendations, assessments, Individual Support Plans (ISPs), and any treatment plans used by the agency (hereafter “care plans”) must be accurate, consistent, and followed precisely for feeding plans, supervision of the individual while eating to maintain safety, proper positioning, and the use of specialized equipment.

2. All staff providing service to an individual must be trained on the individual’s dietary needs, including awareness of proper foods and food textures; supervision needs during meals; proper positioning during meal; and the use of specialized equipment related to the risk of aspiration and choking.

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This Health Alert is intended to make all providers, staff, and other caregivers aware of this serious issue of maintaining skin integrity and preventing pressure injuries. All should become familiar with resources related to the following:

• What are pressure injuries?• Why is preventing pressure injuries important?• Who is at risk for developing a pressure injury?• What are the signs and stages of a pressure injury?• What is the treatment for pressure injuries?• How can pressure injuries be prevented?

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Targets that are considered within the scope of a provider include employees, contracted agents, volunteers and other individuals receiving services from the provider.

If the incident occurred beyond the provider’s responsibility the provider is not to report the incident, but instead should give notice of the incident to the individual’s supports coordinator.

In situations when multiple providers learn of an incident, the provider rendering services for the individual at the time the incident occurred is to report the incident and begin any required investigation within 24 hours. If it cannot reasonably be determined which provider was rendering service at the time of the incident, all providers who are aware of the incident are to report the incident and investigate.

If, at any time, it is determined that an incident is outside of the scope of the provider’s responsibility to report and investigate, then the provider must:a. Ensure prompt action is taken to protect the individual’s health, safety, and rights.b. Contact the victim’s supports coordinator to report the incident. c. Ensure that the SCO has the necessary information to enter the incident report into the electronic incident management system and ensure an investigation is conducted as required.d. Work with the SCO to develop and implement preventative and additional corrective actions as a result of the incident and investigation.

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Providers use the Enterprise Incident Management system [EIM] to report details describing the incident and to document how they managed the occurrence. The Administrative Entities (AEs) and ODP Regional Offices access EIM to monitor and review incident reports and ensure that providers take timely, appropriate and adequate steps to assure the health and safety and protect the rights of the person/persons involved. For this reason, providers must file clearly written, understandable and detailed incident reports within required timeframes. If a report is unclear or incomplete, Administrative Entities (AEs) and/or ODP will return incident reports to providers for additional documentation and/or action.

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This is a list of Reportable Incident Types.

An incident is an event that harms or has the potential to harm an individual. ODP requires providers to report certain defined incidents using the Enterprise Incident Management (EIM) system embedded in HCSIS

Most incident types have secondary categories. An example is Abuse – Improper or Unauthorized use of Restraints.

Incident management is the response to an allegation/event intended to ensure the adequate, appropriate and effective protection of the health, safety and rights of the individual.

Incident management includes all activities related to a reportable incident, from its occurrence and/or allegation, the prompt actions taken by the provider to ensure an individual’s immediate health, safety and well‐being all the way through corrective actions (the steps taken to prevent reoccurrence of the same or a similar event).

ODP has issued an incident management statement of policy. In addition to this policy, there are several other supporting documents that further enhance the incident management process. Providers must read these documents carefully and ensure that all staff are trained on applicable incident management policies, procedures and regulations.

There are two timeframes for the documentation of reportable incidents. Most categories of reportable incidents must be entered into the enterprise incident management system [EIM] within twenty‐four (24) hours of discovery/recognition. There are two exceptions to this rule; medication errors and restraints. These incidents must be entered into the enterprise incident management system within seventy‐two (72) hours of discovery/recognition. Providers report these incidents through the submission of a standardized report in EIM. Providers must be registered in HCSIS in order to be able to file reports in EIM.

Each incident report includes the following:1. Demographic information of the individual involved2. A description of the incident3. Actions taken to protect the individual’s safety4. Results of Investigation5. Corrective actions to protect the individual and or other individuals and prevent further incidents from occurring

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All incidents defined on the slides must be reported within 24 hours of discovery or recognition .

The involvement of law enforcement personnel is reportable in the following situations:

• An individual is charged with a crime, is the subject of a police investigation that may lead to criminal charges, or is the victim of a crime.

• A crime such as vandalism or break‐in that occurs at a provider site.• An on‐duty employee or an employee who is volunteering during off duty time, or

a volunteer who is charged with an offense, a crime or is the subject of an investigation while on duty or volunteering.

• A crisis intervention involving police/law enforcement personnel. • A citation given to an agency staff person for a moving violation while operating an

agency vehicle, or while transporting individuals in a private vehicle.

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All incidents defined on the slides must be reported within 24 hours of discovery or recognition with the exception of medication errors and restraints which must be reported with 72 hours of discovery or recognition.

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There is a standardized process for providers to follow to report incidents.

The process begins with the allegation, discovery, recognition or report of the incident and ends with the closure of the incident by oversight entities.

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Providers need to take prompt action to ensure the individual’s health, safety, and rights when an incident is recognized or discovered. This information includes some of the actions that could be taken.

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When the target is an employee, volunteer or contracting agent of the Provider, the target shall not be permitted to work directly with the victim or any other service recipient during the investigation process until corrective action(s) specific to the target are implemented.

When the target is another individual receiving supports or services, and complete separation is not possible, the Provider shall institute additional protections.

When a participant who is residing with his or her family experiences an incident that jeopardizes the victim’s health and safety, the provider, AE or ODP will seek the assistance of law enforcement or Protective Service Agencies, who have the authority to remove the alleged perpetrator or the victim from the home or environment to ensure safety.

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Protective Service Laws cover all age groups and outline reporting obligations.

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The APS Act [Act 70] • Establishes requirements for reporting, investigating and provision of needed protective services was

implemented to provide for the protection of abused, neglected, exploited or abandoned adults.

• The APS Act protects residents of this Commonwealth between 18 and 59 years of age who have a physical or mental impairment that substantially limits one or more major life activities.

• An administrator or employee of a facility who observes suspected abuse, neglect, exploitation or abandonment or has reasonable cause to suspect that abuse or neglect has occurred will immediately assure the recipient's health and safety.

• After assisting the recipient, an employee or administrator will follow the reporting requirements set forth in the APS Act.

• An administrator or employee who has reasonable cause to suspect that a recipient between the ages of 18‐59 with a disability is a victim of abuse, neglect, exploitation or abandonment will:

• Immediately make an oral report to the statewide Protective Services Hotline by calling 1‐800‐490‐8505. Once the report is made, it will be referred to the APS agency for handling.

• Within 48 hours of making the oral report to the APS hotline, the reporter is required to submit a written report. This report can either be a form that is provided by APS on their website or the reporter may use the First Section of the EIM Incident Report.

• If an employee is alleged to have committed abuse, the IM Bulletin states that in cases where the health and welfare of an individual is in jeopardy, the staff must be removed from providing services.

In addition to the general reporting requirements, an administrator or employee who has reasonable cause to suspect that a recipient is the victim of sexual abuse, serious injury, serious bodily injury or that a death is suspicious, will immediately make an oral report to law enforcement officials. An employee will also immediately notify the facility administrator or a designee following a report to law enforcement officials, unless such notification would jeopardize the investigation or subject the recipient to further risk.

Continued on next page

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The Older Adults Protective Services Act (OAPSA Act 79‐1987) • Established reporting of abuse and provision of protective services for adults over age 60. The Act required

the Department of Aging (PDA) to provide on‐going training for protective services workers. PDA carries out that mandate by conducting periodic "basis protective services" training and annual skills enhancement/enrichment training.

• OAPSA requires employees and administrators of nursing homes, personal care homes, domiciliary care homes, adult daycare centers and home health care providers to report the suspected abuse of any person who is receiving care from the agency (recipient) regardless of age. Statewide Elder Abuse Hotline: 1‐800‐490‐8505

Child Protective Services Act [CPSL] Act 3490The Child Protective Services Law (CPSL) establishes procedures for the reporting and investigation of suspected child abuse. Certain types of suspected child abuse must be reported to law enforcement officials for investigation of criminal offenses. Children under the age of 18 are covered by the Act including those who receive supports and services from the mental retardation system. Providers covered within the scope of this bulletin are required to report suspected child abuse in accordance with the procedures established in the CPSL and the Protective services Regulations. The CPSL defines child abuse as any of the following when committed upon a child under 18 years of age by a parent, person responsible for a child's welfare, an individual residing in the same home as a child or a paramour of a child’s parent.

•Any recent act or failure to act that causes non‐accidental serious physical injury. •Any act or failure to act that causes non‐accidental serious mental injury or sexual abuse or sexual exploitation.•Any recent act or series of such acts or failures to act that creates an imminent risk of serious physical injury or sexual abuse or sexual exploitation. •Serious physical neglect constituting prolonged or repeated lack of supervision or the failure to provide essentials of life including adequate medical care which endangers a child's life or development or impairs the child's functioning.

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When individuals are abused, neglected, injured or victims of crimes, there are resources to assist them physically, emotionally, financially and legally. Organizations have been developed based on the need to support victims through the criminal justice system, recognizing that victim’s needs are oftentimes overlooked. Individuals with disabilities who fall victim to crimes, especially physical violence and sexual assaults, should be encouraged and assisted to access these resources. It is suggested that providers develop relationships with local entities and assist individuals in accessing such services when appropriate.

There are two main types of victim assistance programs: system and community‐based organizations. System‐based programs that generally operate out of a District Attorney’s office provide notification to victims/witnesses of court proceedings. Community based programs are designed to provide support and assistance to victims. Usually, the programs fall under the categories of:

•Rape Crisis/Sexual Assault programs providing services to victims and their family/supporters. Domestic Violence programs provide counseling and temporary housing to victims, as needed.•Crime Victim Services provide supports and assistance to victims of crimes excluding sexual assaults and domestic violence.

There are domestic violence centers, rape crisis centers and victim assistance offices throughout the Commonwealth. In order to locate the most appropriate resource for individuals, you may contact the following statewide organizations. Additional information regarding local resources is available through these organizations:

• PA Commission on Crime and Delinquency [PCCD] (717) 787‐2040• PA Coalition Against Rape [PCAR] [800] 692‐7445 and (717) 728‐9740• PA Coalition Against Domestic Violence [PCADV] 800‐932‐4632• Office of Victim Advocate [crime victim compensation] (717) 783‐7501• Pennsylvania Protection and Advocacy [PP&A] (800) 692‐7443

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Resources

THE NATIONAL DOMESTIC VIOLENCE HOTLINE 1-800-799-SAFE (7233) TTY: 1-800-787-3224

PENNSYLVANIA COALITION AGAINST DOMESTIC VIOLENCE 1-800-932-4632 TTY: 1-800-553-2508 www.pcadv.org

NATIONAL SEXUAL ABUSE HOTLINE 1-800-656-HOPE (4673)

PENNSYLVANIA COALITION AGAINST RAPE 1-800-692-7445 www.pcar.org

To see where the programs are in by county, visit the Pennsylvania Office of Victim’s Services website: http://pcv.pccd.pa.gov.

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Site reports require family notifications as well.

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Providers are responsible to ensure investigations are conducted in a manner consistent with ODP policy. ODP trains and certifies investigators.

Providers send an employee[s] to a four day training course that certifies the person to conduct investigations in the standardized format approved by ODP. This course is offered several times a year in different locations across the state.

All investigators, either contracted or provider employees, must be trained per ODP policy and have attended and passed the four day certification course. The Certified Investigator must be available to initiate the investigation within 24 hours of the report of the incident.

Certification of the investigators is valid for three [3] years, when a recertification course is required to continue as a Certified Investigator.

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The critical incident primary and secondary categories in this slide are required to have an investigation completed per ODP policy.

This table includes the requirements for which incidents require certified investigations. Please note that a few categories of incidents require investigation also by the county and/or ODP. However, all incidents requiring investigation must be investigated by the Provider.

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Providers must dedicate administrative resources to carry out their roles and responsibilities related to incident management.

Someone needs to be ‘in charge’ for the agency to assure a comprehensive approach and understanding of what’s required as well as what is happening.

The provider’s policies must conform to ODP’s policy. The policy should be customized to reflect the provider specific roles and unique practices.

Training, training, training! Initial training, and even annual training is not enough. Providers need to constantly reinforce the importance of reporting incidents as well as how to prevent them.

Providers need to designate a point person[s], incident management representative and certified investigator.

Every incident requires closure. Providers need to identify corrective actions, when applicable, and assure implementation of those corrective actions.

Providers must also use incident data to examine their overall performance.

Within the administrative structure to fulfill IM responsibilities, providers must evaluate the quality of the investigations; a peer review process is one component. This process is outlined in the Peer Review Manual.

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Providers must have the roles designated above to comply with ODP policies.

A person may have more than one role in the incident management system. It is the agency’s responsibility to make sure that the differing roles are handled in a clear and concise manner which is separate from each other, so that the responsibilities associated with each role are conducted objectively. The nature of each individual incident will dictate what role(s) a person undertakes during the process.

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Taking prompt action to protect the individual's health, safety and rights. may include dialing 911, escorting to medical care, calling the Protective Services Hotline, arranging for counseling, or referring to a victim’s assistance program. When an individual is the victim of a crime, the individual must be offered the support of a victim's assistance program.

Applicable laws and regulation include but are not limited to the following:• The Mental Health and Mental Retardation Act of 1966 (50 P.S. §§ 4101‐4704)• The Adult Protective Services Law (Act 70)• Title XIX Social Security Act (42 U.S.C.A. §§ 1396‐139br)• 18 Pa. C.S. § 2713 (relating to the neglect of care‐dependent person)• The Child Protective Services Law (23 Pa. C.S. §§ 6301‐6385)• The Older Adults Protective Services Act (35 P.S. §§ 10225.101‐10225.5102)• Elder Care Payment Restitution Act (35 PS §§ 10226.101‐10226.107)• Early Intervention Services System Act (11 P.S. §§ 875.101‐875.503) • The Whistleblower Law (43 P.S. §§ 1422‐1428)

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The Point Person shall also:

• Ensure that the individual’s family, guardian, or designee is informed of the incident within 24 hours unless otherwise indicated in the individual’s support plan.

• Notify appropriate supervisory/management personnel, as specified in agency policy.

• Ensure that the individual’s family or designee is notified of the findings of any investigation unless otherwise indicated in the individual’s support plan.

• Ensure the implementation of policies and procedures that support the initiation of initial incident reports within 24 hours of discovery and the finalization of incident reports within 30 days of the incident.

• Follow the incident until closed to ensure all timelines are met and all pertinent information (including prevention and risk mitigation measures) about the incident are included in the final incident report.

• Determine when incident timelines may not be met and an extension will need to be filed in the electronic incident management system.

• Respond to concerns from individuals and families about the reporting and investigation processes.

• Follow up on feedback received from initial and/or final management reviews.

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The incident management (IM) representative is the person designated by the provider with overall responsibility for incident management. Every provider must have their own IM representative. The IM representative must be a certified investigator regardless of the intent for this position to complete investigations. This certification must be obtained within six (6) months of assuming the role of IM representative. The IM representative may delegate the activities within their organization but will maintain the overall responsibility to ensure their completion per policy and procedure.

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Certified Investigators may be employees or contractors, although must be available to initiate an investigation within 24 hours and complete investigative witness interviews within 10 days.

A certified investigator is a person who has been trained and certified by the Department to conduct investigations. The certified investigator will:1. Conduct investigations using the process and standards of quality outlined in the current ODP certified investigator’s manual.2. Enter a summary of findings in ODP’s electronic incident management system.3. Turn over complete original investigation file to the agency to be able to complete administrative review.4. Participate in the CIPR process.

To be a certified investigator, the certified investigator shall:1. Have a high school diploma or general education diploma.2. Be 21 years of age or older.3. Meet the criminal history checks under §51.20 (relating to criminal history checks) and, if applicable, the child abuse clearance provisions under §51.21 (relating to child abuse clearances).4. Complete the Department’s prerequisite requirements within 3 months of enrolling and prior to completion of the certification training.5. Complete the certification training and pass the exam. A certified investigator shall be recertified every 3 years.

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Oversight entities such as Supports Coordinator Organizations [SCO’s], Administrative Entities [AEs] and ODP Regional Offices, are completing concurrent reviews of all reportable incidents and providers need to be prepared to field questions from multiple sources during the initial incident report review process. If an incident required an investigation, there could also be a need for a provider to coordinate investigation activities with an investigator from an oversight entity. Providers will be contacted by the appropriate entity if a coordination of efforts is needed.

Providers must carefully monitor timelines for the incident management process as the incident moves beyond the first 24‐48 hours. This is because providers only have thirty (30) days to complete all of the steps of the incident management process. Therefore, careful development, implementation and monitoring of strong incident management procedures will ensure providers adhere to timeframes in regulation. For example, providers need to account for the extra time that critical incidents require, for an administrative review, that can impact the timeline.

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Incident management is a key component of ODP’s Risk Management system which is integral to maintaining ODP’s assurances that the health, safety and rights of individuals receiving services are protected. Within the ODP Risk Management system, incident management provides for the recognition and timely reporting of adverse events that jeopardize or have the potential to jeopardize the health, safety and rights of individuals receiving services. Upon discovery of an adverse event, policy requires immediate response to take corrective actions that adequately, appropriately and comprehensively address the unique circumstances of each event.

Incident Management is reactiveIncident management is the process implemented when an event as described in the Incident Management Bulletin occursProviders must allocate resources to and implement an incident management policy

Risk Management is proactiveOne word that describes Risk Management is PREVENTIONRisk management uses what is learned from prior occurrences in order to prevent future occurrences.

An effective risk management system identifies factors that put individuals at risk and develops practices that reduce risk.

Managing incidents is reporting, taking actions to protect the individual, investigation and ensuring corrective action[s] are completed.

Risk Management is collection of data and analysis to identify trends and patterns.

Providers are required to review and analyze trends and patterns found in their incident management data on a quarterly basis to identify systemic issues that need to be addressed to reduce the level of risk to individuals who receive services.

Provider risk management teams review and analyze the data to discuss trends and patterns and develop strategies to prevent incidents and reduce risk. After implementation of these strategies, providers evaluate the associated data to determine if the improvement plan was successful or if alternative strategies are needed.

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Critical Questions to ask yourselves when determining your response to an incident, a series of incidents and/or a trend• Was everything done to assure health/safety and protect the rights of the individual?• Was everything done to assure health/safety of others in immediate jeopardy?• Was response adequate and appropriate?• Was everything that could be done, done? If not, why not?• What else could have been done?• Could it have been done better?• What can be done to prevent recurrence?• Are others at risk for this occurring to them? Who? Has it been addressed?• Is this a systemic issue?

Corrective Action & Prevention questions• Is the person safe now?• How do we support the person now?• How can we prevent this from happening again?• Was the environment checked for possible cause? Corrections made to issues found?• Does the person have a history of this injury?• Are there medical concerns related to the injury? If so, what follow up actions were

taken?• Was the injury due to equipment failure? If so what corrective measures were taken?• If incident was due to choking or falling, what actions were taken to prevent recurrence?

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Providers use incident management reports to analyze aggregated data. This information facilitates the identification of patterns and trends regarding factors that influence occurrences. Understanding factors that influence occurrences allows providers to implement preventive measures for the individual and at the system level.

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Thank you for reviewing Module 4.

Return to the Provider Applicant Orientation Course:• Complete the training confirmation.• If you affirmed that you have reviewed the information and are ready to take the test, you will

see a link for Module 2: Test. • Click the link to open the test. Answer all questions, then click the “submit” button and then

“submit all and finish”.

After you submit your test responses, you will receive a score and feedback on next steps. If you passed the test, you will be able to proceed to the next Module.

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Documents

PA Dept. of Human Services, Office of Developmental ...€¦ · be entered into the enterprise incident management system within seventy‐two (72) hours of discovery/recognition