New Mexico Human Services Department

Critical Incident Management System Training Guide

If you are a provider of Behavior Health Services, please refer to the BH

Protocols document at:

https://criticalincident.hsd.state.nm.us

2 September 2015

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.

The MCO incident reporting process must be made available to members, authorized representatives, and guardians.

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.

3 September 2015

This presentation describes the statewide reporting requirements for incidents involving Home and Community Based Services (HCBS) members enrolled in Centennial Care.

The Human Services Department (HSD) website address used to report Critical Incidents involving a Centennial Care member is:

https://criticalincident.hsd.state.nm.us

4 September 2015

New Mexico State law requires reporting alleged/suspected incidents.

Incident reporting is a mechanism to ensure the health and safety of members receiving Centennial Care (CC)/Fee for Service (FFS) services.

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.

5 September 2015

Statutes and regulations define the legal requirements for properly reporting incidents in a timely and accurate manner. NMSA 1978, Section 27-7-30 Adult Protective Services http://law.justia.com/codes/new-mexico/2006/nmrc/jd_ch27art7-b845.html NMSA 2013, Section 32A-4-3 NM Children Code http://law.justia.com/codes/new-mexico/2006/nmrc/jd_32a-4-3-adad.html NMAC 7.1.13 Incident Management http://dhi.health.state.nm.us/elibrary/regs/7.1.13NMAC_Incident_REP_INTAKE.pdf NMAC 8.308.21.13 Quality Management

http://www.hsd.state.nm.us/Looking for information/rules and statutes

6 September 2015

Agencies that do not comply with incident reporting requirements are in violation of State statutes and Federal regulations.

Agencies may be sanctioned up to and including termination of their provider agreement by a MCO or by HSD-Medical Assistance Division (HSD-MAD).

7 September 2015

MCOs are required to review and process all Critical Incidents submitted to the HSD website for their enrollees within 24 hrs. of receipt, including reporting all Abuse, Neglect and Exploitation (ANE) to Adult Protective Services (APS)/Child Protective Services (CPS).

MCOs are required to submit all incidents they become aware of through their activities with the members.

MCOs are required to train all staff who work with members 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 members, APS/CPS, local law enforcement, tribal social services and with the agencies that provide services.

8 September 2015

MCOs 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 HSD-MAD monthly and quarterly. This includes reports on the total Centennial Care population, on BH critical incidents and on incidents involving members of Self Directed Services.

9 September 2015

Contracted Centennial Care providers are required to verify eligibility prior to providing services. (NMAC 8.302.1.11)

When verifying eligibility the Category of Eligibility (COE) is available to you.

Correct COE entry is required when filing a Critical Incident report to HSD-MAD.

10 September 2015

NM Centennial Care Website: https://nmmedicaid.acs-inc.com

Provider Relations Call Center: 800-299-7304 NM HIPAA Helpdesk via email:

HIPAA.Desk.NM@xerox.com, or telephone: 800-299-7304/505-246-0710 or Fax 866- 226-1473 Xerox Automated Voice Response System

(AVRS) at 800-820-6901 24 hrs. a day, 7 days a week. 11 September 2015

SSI 001 – SSI Aged 003 – SSI Blind 004 – SSI Disabled

Institutional 081 – Institutional Aged 083 – Institutional Blind 084 – Institutional Disabled

12 September 2015

Home and Community Based Services 090 - HIV/AIDS 091 - Home and Community Based Waiver – Aged 092 - HCBS Brain Injury 093 – HCBS Aged and Disabled 094 – HCBS Disabled 095 – Medically Fragile*

Affordable Care Categories 100 – Adult Group Ages 19-64; Must also have “NFLOC”

– Nursing Facility Level of Care. 200 - Parent/Caretaker Relative; Must also have “NFLOC”

– Nursing Facility Level of Care. *Starting 01/01/2016

13 September 2015

COE 100 & 200 recipients must also have a Nursing Facility Level of Care (NFLOC).

If a NFLOC is not designated for the recipient

(COE 100 & 200), then the Critical Incident is NOT reported on this website.

14 September 2015

If the Incident Report is for a recipient enrolled in: DD Waiver (COE 096), or Medically Fragile Waiver (COE 095)* file the report to:

NM Dept. of Health (DOH) Incident Management Bureau: Telephone: (800) 445-6242

FAX: (800) 584-6057

If the Incident Report is for a recipient receiving services from a Nursing Home:

NM Dept. of Health (DOH) Program Operations Bureau Telephone: (800)752-8649 or (505)-476-9025

FAX: (888)576-0012 *COE 095 reportable to DOH through12/31/2015 then will be reported to the HSD Critical Incident website starting 01/01/2016.

15 September 2015

All incidents involving: Abuse Neglect Exploitation Deaths Emergency Services Law Enforcement Environmental Hazards Elopement/Missing

16 September 2015

All incidents of ANE, and any death suspected to be a result of ANE must be reported to APS or CPS as well as to the HSD Critical Incident Portal.

APS/CPS 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.

17 September 2015

If the member is 18 years of age or older, a report of Abuse, Neglect, or Exploitation must be reported to:

Adult Protective Services (APS) Telephone: 866-654-3219

FAX: 505-476-4913

If the member is under the age of 18, a report of Abuse, Neglect or Exploitation must be reported to:

Child Protective Services (CPS) Fax : 505-841-6691

18 September 2015

Is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.

Abuse can be inflicted upon the member or inflicted by the member.

Self Abuse is defined as the abuse of one’s self or abilities.

19 September 2015

The member is threatened with being homeless.

The member is pushed or roughly handled while receiving care.

The member is sexually assaulted.

The member is made to do without food, water, or bathroom access as punishment.

20 September 2015

The member is doubling their pain medication and will not see the doctor.

The member’s alcohol consumption results in frequent Emergency Room (ER) visits.

The member threatens or attempts suicide.

The member cutting themselves or other self inflicted injury. 21 September 2015

The member sexually harasses caregivers.

The member threatens caregivers or their

families either verbally or physically.

The member consistently uses racial or ethnic slurs when talking to caregivers.

22 September 2015

Neglect means the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.

[7.1.13 NMAC]

23 September 2015

Agency 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 bills do not purchase sufficient food and supplies do not arrange or transport to needed medical

care do not provide support as agreed in the

personalized service plan for the member. (staying overnight, preparing meals, etc.)

24 September 2015

Does not eat enough to stay well or “forgets” to eat.

Refuses to bathe or change clothes. Forgets or refuses prescription medications. Does not have heat or electricity because bills

are not paid. Consistently refuses to allow services to be

delivered despite obvious need.

25 September 2015

The deliberate misplacement, misuse or wrongful (temporary or permanent), use of a member’s belongings or money without the member’s consent. Incidents of exploitation may also be reports of alleged Fraud. The Fraud field is selected if an incident involves misuse of

Centennial Care or other government funds:

26 September 2015

Caregiver or others use member’s ATM/debit card for their own purchases, or borrows money and does not pay it back.

People move into the home uninvited and/or without paying rent or utilities.

Caregiver convinces member to sign timesheet for hours not worked.

Caregivers or others, are taking the member’s property, or the Member’s medications are frequently missing.

27 September 2015

Examples of Possible Fraud: The caretaker claims time for work not

completed or for services not rendered. CC/FFS pays for services diverted to

inappropriate use (private sale of CC/FFS paid goods).

28 September 2015

The website offers the following choices when filing a Critical Incident to report a Death: Natural or Expected Unexpected Homicide Suicide

29 September 2015

Natural or Expected Death — is a death caused by a long-term illness, a diagnosed chronic medical condition, or advanced age.

Unexpected Death — is a death caused by an accident, an unknown or unanticipated cause, or not attributed to a current medical diagnosis or chronic condition.

Homicide — is a death caused by the killing of one person by another person.

Suicide — is a death caused by intentionally killing oneself.

30 September 2015

Member is under Hospice care at the time of death, and the cause of death is related to their hospice diagnosis.

Member’s death is attributed to their disease process.

Member is of advanced age (90+) and the cause of death related to their disease process.

31 September 2015

Accident Death unlikely to be attributed to

diagnosis/condition.

The caregiver enters the home and finds the member dead on the floor or in bed.

32 September 2015

If the member is in Hospice care, the agency following the hospice plan of care, will not be responsible for reporting neglect/abuse, refusing food, medications etc.

A death under the care of a Hospice agency is considered a natural/expected death – if the death is secondary to the hospice diagnosis.

33 September 2015

Emergency Services refers to the provision of medical care to a Member that was not planned or anticipated.

Emergency Services in general are services that would not routinely be provided by a Primary Care physician.

Emergency Services are provided in times of crisis and/or in an urgent manner.

Emergency services include Emergency Room, EMS, Law Enforcement and any call to 911.

34 September 2015

911 is called. The member gets sick and the caregiver

takes them to the ER. The member goes to the ER and then leaves

before being seen or treated by medical staff.

The ER releases the member without providing any treatment.

35 September 2015

The member is at a doctor appointment and the doctor sends them to the ER for a routine test or procedure (for example radiology studies, lumbar puncture, other laboratory testing).

The member 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.

Services provided at an urgent care facility.

36 September 2015

Law Enforcement Intervention is defined as the arrest or detention of a person by a law enforcement agency. Involvement of law enforcement in a an incident or event, or placement of a person in a correctional facility.

Involvement of Law Enforcement is reportable if it affects the health or safety of a member, or it prevents the member from receiving services.

37 September 2015

The member’s primary caregiver is arrested or detained.

The member is arrested and/or incarcerated, or picked up for a bench warrant or for a parole violation.

The police are called to do a ‘well check’ .

The member is detained in Protective Custody.

The member is transported by police to a hospital or mental health facility, voluntarily or involuntarily.

38 September 2015

Environmental Hazard is defined as an unsafe condition that creates an immediate threat to life or health of a recipient.

39 September 2015

A fire or flood has created a hazard in the home.

Lack of repairs that create hazards: Roofs that leak or broken windows & doors. Unsafe electrical or plumbing installations.

Utilities previously in place have been “shut off”.

Hoarding, foul smells, piles of garbage, or clutter that impedes normal movement to bathrooms or exits.

Animals that are out of control in the home and are threatening services or creating more waste that can be cleaned timely.

40 September 2015

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 member or others in the home. Family members or others in the home threaten,

frighten or harm caregivers or others who are providing services.

41 September 2015

The 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.

42 September 2015

Elopement - is defined as the act of running away;

the deliberate act of not being where one is supposed to be.

Missing - the act of not being present, or lost; the

unexplainable fact that the member is not where they are supposed to be.

Wandering - Used for those recipients who leave

without intent to stay gone. May be lost or unaware of their surroundings.

43 September 2015

Submit incident reports for members of Centennial Care and Fee for Service through the HSD Incident Reporting website: https://criticalincident.hsd.state.nm.us.

Remember that there is a limited list of accepted COEs.

Incidents must be reported within 24 hours of knowledge of the incident.

Reports need to be accurate and concise.

To get access to the website send an email to HSD-QB-CIR@state.nm.us.

44 September 2015

The agency delivering an authorized service submits the incident report within 24 hours of knowledge of the occurrence.

The MCO submits an incident report within 24 hours of an occurrence discovered during MCO/member activities (assessment, phone call, etc.).

45 September 2015

There are many people involved in the care of a member. For members with Self Directed Community Benefits (SDCB), they include but are not limited to:

Authorized Agent (AA) Authorized Representative Care Coordinator (CC) Employer of Record (EoR) Financial Management Agency (FMA) Legal representative Support Broker Vendors

Any of the above persons can file an Incident report as long as they have access to the HSD Critical Incident report system.

46 September 2015

Specifics on verifying eligibility can be found on slide # 10 “Category of Eligibility. Example of a member with SDCB:

47 September 2015

Go to the HSD Critical Incident website (https://criticalincident.hsd.state.nm.us) and access the Critical Incident Reporting Form.

Fill out all required information (fields highlighted in yellow

are required).

48 September 2015

Once the report has been submitted, any updates necessary can be entered using the diary function.

49 September 2015

Be accurate Wrong information slows response to the issue and may

violate HIPAA regulations. Have the correct information easily available to the

reporter. Make sure the right people know about the incident APS/CPS receive all Abuse, Neglect and Exploitation reports

that have been submitted to the MCO or HSD. If you want APS to share any information, you must call in the report with your agency name and phone number.

Self Directed members should inform their Support Brokers and Service Coordinators about any incidents.

50 September 2015

Be comprehensive Make sure you have included the names and the concise information needed to tell the story. The diary entries are available for more detailed information or updates.

Be Brief

Allegations, opinions and information not regarding the event can confuse the issue and slow down the responsiveness.

Expect the call Make sure your agency has all the relevant documentation available for review.

51 September 2015

If you have questions about the website, Critical Incident reporting, or the content of this presentation you may email:

HSD-QB-CIR@state.nm.us You will receive a response to your questions within 48 hours. Please allow additional time for weekends and holidays.

52 September 2015