1. REPORTING GUIDELINES Introduction to the Reportable Events Handbook

2. CONTEXT Uniqueness of the SVH program – Owned, operated, managed and financed by the states – VA provides money for construction and per diem – VA assures Congress that SVH meet VA standards Challenging role – Friendly, consultative, partnership and cursory inspections vs. – The demand for increased oversight (July 2001 GAO) John P. McEwan, LCSW

3. THE CONCERN Some facilities have significant care deficits Bad things happen in good homes Annual inspections, though informative, are too infrequent VA is often unaware of adverse events that become highly publicized “Bad news doesn’t get better with age” John P. McEwan, LCSW

4. PREVIOUS GUIDANCE Code of Federal Regulations (CFR) Unpublished SVH Patient Safety Improvement Handbook Deputy Under Secretary for Health for Operations and Management (10N) dated Nov 14, 2006 entitled SVH Program: Requirements for Immediate Notification John P. McEwan, LCSW

5. PROBLEM WITH CURRENT PROCESS Inconsistent Implementation by local VAMC – Laissez faire vs. demanding reporting requirements Inconsistent response by SVH – Perception that reporting requirements are too stringent – Not necessarily required by law or regulation John P. McEwan, LCSW

6. THE VISION Nancy Quest envisioned a unifying document Team of Stakeholders – Representatives of the National Association of SVH – Representatives of VACO GEC – VISN liaisons – SVH team leaders – RNs, SWs, Administrative staff John P. McEwan, LCSW

7. THE VISION The document would become a handbook – (As of Feb 7, 2011 still in concurrence) It would include all reporting requirements currently in the Federal Regs and supplant all other previous guidance It will minimize the burden on State Homes and VA John P. McEwan, LCSW

8. THE VISION It would limit reporting to those items of greater significance It would emphasize the partnership of VA and SVH and encourage mutual cooperation

9. MAJOR ELEMENTS A distinction between “Required” and “Requested” reports No requirement for RCA State home may report using their own format (with some guidelines) Reporting time frames are provided Not all adverse events need reporting Onus on local VA facility to create I.B. as needed John P. McEwan, LCSW

10. REQUIRED REPORTS Those reports that are cited in the Federal Regulation – Sentinel Events – Change in administration John P. McEwan, LCSW

11. SENTINEL EVENTS Sentinel Event is an adverse event that results in a loss of life or limb or permanent loss of function. Examples include: – Any resident death, paralysis, coma or other major permanent loss of function associated with a medication error, or – Any suicide of a resident, including suicides following elopement (unauthorized departure) from the facility; or John P. McEwan, LCSW

12. SENTINEL EVENTS Examples cont. – Any elopement of a resident from the facility resulting in a death or a major permanent loss of function; or – Any procedure of clinical intervention, including restraints, that result in death or a major permanent loss of function ; or – Assault, homicide or other crime resulting in patient death or major permanent loss of function; or John P. McEwan, LCSW

13. SENTINEL EVENTS Examples cont. – A patient fall that results in death or major permanent loss of function as a direct result of the injuries sustaining in the fall – NOTE: Falls that are unlikely to result in major or permanent loss of function are considered adverse events John P. McEwan, LCSW

14. CHANGE IN ADMINISTRATION Change in administration: The state must give written notice at the time of the change, if any of the following change: – The State agency and individual responsible for oversight of a State home facility; – The State home administrator; and – The state employee responsible for oversight of the State home facility if a contractor operates the State home. John P. McEwan, LCSW

15. REQUESTED REPORTS Change in nursing administration: – Director of Nursing (DON)/Director of Nursing Service (DNS) Substantiated allegations of mistreatment, neglect, abuse, or misappropriation of resident property. – When a facility investigation determines that an allegation is substantiated it should be reported John P. McEwan, LCSW

16. REQUESTED REPORTS Elopements pursuant to state regulations Infectious outbreaks – Events reportable to Public Health agencies pursuant to state regulations Resident to resident altercations resulting in any injury that is other than minor John P. McEwan, LCSW

17. REQUESTED REPORTS Adverse Events - – Many adverse events such as minor medication errors without catastrophic outcomes are managed by the SVH in the context of their quality improvement programs. It is NOT necessary for SVH to report theses to the VAMC of jurisdiction. – Falls with significant injury which require the resident to be sent out of the facility for medical intervention should be reported. John P. McEwan, LCSW

18. REQUESTED REPORTS Inspection / Surveys by oversight agencies: – Copies of annual surveys conducted by state licensure oversight agencies – Unexpected surveys or inspections by governing oversight agencies when a deficiency is cited and a plan of correction is required. John P. McEwan, LCSW

19. REQUESTED REPORTS Information regarding the SVH that appears in local or national media – The sharing of information that appears in the media may be mutually beneficial to DVA and SVH. Consequently, relevant information should be shared as it becomes available by both the SVH and medical center of jurisdiction. John P. McEwan, LCSW

20. PROCESS VAMC of Jurisdiction is responsible to communicate the reporting guidelines and relevant contact information to the SVH in their area John P. McEwan, LCSW

21. PROCESS SVH may report using their own preferred format – Personal Identifiers should be avoided. – Reports should include: Date of report Brief Statement of Issue Background, current status and actions Current Census Percentage of Veterans in the home Contact information John P. McEwan, LCSW

22. PROCESS The SVH facility management must report sentinel events to the director of the VA medical center of jurisdiction within 24 hours of identification. In addition to the initial reporting requirement, SVH are also required to review and analyze sentinel events resulting in a written report no later than 10 working days following the initial report.

23. PROCESS The 10-day report may follow the SVH preferred format for reporting with the considerations outlined above. RCA is no longer required The SAC grid is no longer used to determine evidence of a sentinel event.

24. PROCESS VAMC Facility of Jurisdiction Reports shall be forwarded to the VISN liaison within 1 business day by the local VAMC of jurisdiction Reports of a serious nature must include an issue brief and cover page – Sentinel events – Significant media events – Changes in administration (Administrator or DON/DNS) John P. McEwan, LCSW

25. PROCESS VISN SVH Liaison should forward all reports of a serious nature including all sentinel events, significant media events as well as changes in administration (Administrator or DON/DNS) to VACO Office of G&EC as well as 10N. VISN SVH Liaison is expected to use discretion in determining what additional reports are sent to VACO. John P. McEwan, LCSW