INCIDENT MANAGEMENT: SOUP TO NUTS Pamela Treadway, M.Ed. Senior Clinical Consultant February 13, 2014

Agenda What is Incident Management? Incident Management Responsibilities EIM Incident Management Roles Navigating and Creating Incidents Understanding the Incident Flow IM Tips

What is Incident Management?

What is Incident Management? Risk management process – assuring the health, safety, and rights of participants receiving services Standardized, web-based mechanism for reporting incidents in the Enterprise Incident Management system (EIM) Incident Management enables appropriate users to record incidents, track the status of recorded incidents, document corrective actions taken to prevent future occurrences, close incidents, and analyze aggregate incident data reported in EIM.

Incident Management Responsibilities

Provider Responsibilities Enter incidents that occur while providing services to a participant Timely documentation and finalization of incidents in EIM First section due within 24 hours Final section due within 30 days Communicate with the SC and families regarding incidents Appropriate follow-up and corrective action

Supports Coordinator Responsibilities Review with participants and families how to report incidents, especially concerns regarding abuse, neglect or exploitation SCs need to enter incidents if directly reported to them by participants or families unless providers are responsible SCs need to review incident reports. Monitoring must include follow-up to ensure any corrective actions have been implemented and are effective. Consult Chapter 8 in Supports Coordinator Manual for detailed information on Incident Management, including incident definitions

EIM Incident Management Roles

EIM Roles Initial Reporter: Any person who witnesses an incident or is the first to discover or be made aware of the signs of an incident (not a data entry role in EIM) Point Person: Receives verbal or written reports or allegations of incidents from participants, families and Initial Reporters and enters the incident information in EIM Incident Reporter: Designated by the Provider with overall responsibility for Incident Management reporting including ensuring that the activities of the Initial Reporter and Point Person have been completed. The Incident Reporter is also responsible for the submission of the incident report within 30 days of the incident Certified Investigator: Person who has been trained and received a certificate in investigation from ODP. Certified Investigators promptly conduct investigations when assigned and enter a summary of their investigation findings in the EIM Incident Report

EIM Roles If you have never entered an incident, please immediately assure that you have the appropriate EIM roles assigned to your HCSIS User ID. Your HCSIS BP Administrator can assign EIM roles via Identity Manager If he/she does not have their own roles mapped to EIM, they must first contact the HCSIS Help Desk to get their roles assigned Do not wait until you have to file an incident to find out if you have the appropriate roles!

Certified Investigator Roles New Certified Investigators must have their names added to the dropdown menu. Email the Provider Support mailbox (ra- basprovidersupprt@pa.gov) with the request Email should include the CI’s name (as it should appear in dropdown), HCSIS User ID, and copy of the certificate showing the investigator is currently certified BAS will make the request to the HCSIS Help Desk Process typically takes a day or two for the CI’s name to appear in dropdown

Incident Categories

BAS Primary Incident Categories What are the incidents that need to be reported? 24 Hour Reporting: Death Suicide Attempt Hospitalization Psychiatric Hospitalization Emergency Room Visit Abuse Individual to Individual Abuse Neglect 24 Hour Reporting: Missing Person Injury Requiring Treatment Beyond First Aid Disease Reportable to the Department of Health Fire Misuse of Funds Rights Violation Law Enforcement Activity Crisis Event Emergency Closure Use of Restraint, even if authorized 72 Hour Reporting Medication Error

Navigating and Creating Incidents In EIM

Incident Management Navigation Two Log-In Options: Log into EIM through HCSIS Navigate to the HCSIS Portal via https://www.hcsis.state.pa.us. Login to HCSIS by clicking HCSIS Login and entering your username and password. Click [LOGIN] to navigate to the HCSIS Home Page.  Click M4Q in the yellow, first level menu bar. Click EIM in the gray, second level menu bar. The My Dashboard screen appears.  

Incident Management Navigation Log directly into EIM from landing page Navigate to EIM via https://www.hhsapps.state.pa.us/eim/default.aspx and click [Login to EIM] Enter your HCSIS username and password and click [LOGIN] to navigate to the EIM landing page. The My Dashboard screen appears.

Creating a New Incident

BAS Report Types Individual Incidents Crisis Event Restraint Medication Error Optionally Reportable Event (Don’t use)

“How To” Trainings/Resources For more detailed training on how to create, enter, and submit incidents, consult the Learning Management System.

Understanding the Incident Flow

What is the incident flow? FIRST SECTION: Provider creates a new incident and submits the first section within 24 hours of incident occurrence or first being made aware than an incident occurred. Once submitted, first section becomes read-only BAS receives alert BAS views First Section in EIM which marks the incident as reviewed

What is the incident flow? FINAL SECTION: Provider (Point Person)thoroughly completes the final section of the report within 30 days. Incident Reporter finalizes which submits the incident for BAS review and approval BAS Incident Reviewer initiates and conducts management review to approve (close) or reject incident. If rejected, incident is returned for to provider for follow-up/clarification

How do I manage my incidents? There are no provider alerts to track the incident throughout the process The mechanism for tracking incidents is through the EIM My Dashboard

Investigations

A few pointers about investigations Only select a certified investigator from your own provider organization or with whom you have an agreement Investigations need to begin promptly Investigator must complete and submit their section before incident can be submitted to BAS Be sure the outcome/determination of the investigation is consistent throughout the incident sections (CI section and final section verification of incident classification screen) Determinations: Confirmed, Not Confirmed, Inconclusive

Investigations

Investigations

Investigations

Incident Management Tips

First Section Considerations ACTIONS TAKEN TO PROTECT HEALTH AND SAFETY~ What was done during the event to protect the health and safety of participant and others INCIDENT DESCRIPTION~ succinctly and chronologically detail what happened during the incident. Include dates, times, people involved, and the current status of the participant. Information should be objective, refrain for inserting subjective comments ~ Nothing but the facts! Discovery Date ~ Use date when entering the report if filing an incident that is not timely. Use date of occurrence for the primary and secondary categories

First Section Considerations Law Enforcement category~ use “crisis intervention” as the secondary category if police were called during a behavioral crisis Crisis Events ~ indicate if another incident needs to be filed as a result of the crisis event (e.g., ER visit, Psych Hospitalization) Use Link feature to “connect” incidents if they are directly related (e.g., crisis event and a resulting psychiatric hospitalization) When two separate incident reports are linked together (e.g., crisis event and ER visit), each report needs to capture the information relevant to the incident category. They should NOT be exact duplicates!

Final Section Considerations Complete Witness screens if others were present during the incident Target Information refers to the person being investigated If Individual to Individual Abuse, use the individual’s first name initial, last name initial, and last 4 digits of social security number (WJ 1234) Complete Notifications screen ~ SC should be notified, avoid stating “team” Crisis Events require a team meeting within 10 days of crisis, please enter date of team meeting. If no meeting, please document why in the Additional Information Section

Final Section Considerations Assure Corrective Actions are captured. Include what was done or will be done to prevent future occurrences (e.g., reviewing and updating BSP, retraining of staff, modifying environment, new instructional strategies). Be specific! Complete Hospitalization screen for medical hospitalizations and psychiatric hospitalizations Hospitalization: Do not finalize the FINAL SECTION until participant has been discharged. For all incident reports, use the Additional Information section to capture new information that was not previously captured in the first section, or to clarify/correct previously reported information.

Final Section Considerations Remember to use the “add” feature correctly when entering information on screens that require multiple entries (e.g., add to grid) Do not submit final section until the incident has been resolved Request a Report Extension if the Final Section cannot be completed in 30 days (e.g., participant has not been discharged from hospital) Email the Provider Support Mailbox if extension is needed.

Frequent Reasons for non-approval of incidents Incomplete reports Lack of corrective action Incorrect incident categorization Lack of detail **Using the IM tips discussed above should greatly increase the likelihood of an incident being approved on first management review**

Resources

Incident Management Resources Supports Coordinator Manual, Chapter 8 Provider Manual Learning Management System (LMS) EIM Captivate Tools EIM User Guide For technical assistance: ra-basprovidersupprt@pa.gov