Why Report Incidents? New Mexico State law mandates
requirements for reporting alleged incidents. Incident reporting is
a mechanism to ensure the health and safety of consumers receiving
Medicaid services.
Slide 3
Why Report Incidents? Incidents are reported to improve service
quality by identifying issues or areas of concern. An incident must
be reported before it can be investigated.
Slide 4
INCIDENT ANAGEMENT PRINCIPLES All adults and children receiving
Home and Community Based 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 Consumers, legal representatives, and guardians
must be made aware of and have available incident reporting
processes 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.
Slide 5
New Mexico Statutes/Regulations. In recognition of the need to
report such incidents, the State of New Mexico provides statutes
and individual program regulations which define the expectations
and legal requirements for properly reporting consumer- involved
incidents in a timely and accurate manner.
Slide 6
List of Statutes and Regulations Adult Protective Services -
NMSA 1978, Section 27-7-30
http://law.justia.com/codes/new-mexico/2009/chapter-27/article-7/
Department of Health - 7.1.13 NMAC
http://dhi.health.state.nm.us/elibrary/regs/7.1.13NMAC_Incident_REP_INTAKE.pdf
Personal Care Options - 8.315.4.12 NMAC B. (14), (15)
http://www.hsd.state.nm.us/mad/pdf_files/provmanl/prov83154.pdf
CoLTS C Waiver - 8.307.18.10 NMAC E.
http://www.nmaging.state.nm.us/pdf_files/CoLTS-provider-
pdfs/8_307_18_CoLTS_C_Regulations.pdf Mi Via Waiver - 8.314.6 NMAC
http://www.hsd.state.nm.us/mad/pdf_files/provmanl/prov83146.pdf
Slide 7
HSD/MAD/QAB Incident Management System This presentation and
the Incident Management Guide describes the statewide reporting
requirements for all incidents involving consumers served under
certain Medicaid-funded, Home and Community Based service programs.
These programs include CoLTS C Waiver, Personal Care Option Program
(PCO) Mi Via.
Slide 8
What Types of Incidents Are We Required to Report? All
incidents involving: abuse, neglect, and exploitation, natural or
unexpected deaths, emergency services, law enforcement,
environmental hazards.
Slide 9
Abuse is defined as: Abuse means the willful infliction of
injury, unreasonable confinement, intimidation, or punishment with
resulting physical harm, pain or mental anguish [7.1.13 NMAC].
Slide 10
Abuse Consumer is threatened with being homeless or placed in a
nursing home. Consumer is pushed or roughly handled while receiving
care.
Slide 11
Abuse/Self Abuse Abuse includes self abuse Agencies may write
in self-abuse Self abuse will be documented in the narrative
section.
Slide 12
Self-Abuse Consumer is doubling up on pain medication and will
not see the doctor. Consumers alcohol consumption results in
frequent ER visits or law enforcement interventions.
Slide 13
Abuse/Caregiver abuse Caregiver abuse is important to report
Seriously impacts the delivery of services Isolates the consumer
Service coordinator must be notified Description of abuse will be
documented in the narrative section of the report.
Slide 14
Neglect is defined as: Neglect means the failure to provide
goods and services necessary to avoid physical harm, mental
anguish, or mental illness [7.1.13 NMAC].
Slide 15
Neglect Caregiver/family do not provide sufficient food or do
not allow others to provide food. Medical appointments and
treatments are routinely not attended. The home is not warm or cool
enough.
Slide 16
Neglect/Self Neglect Neglect includes self neglect. Agencies
may write in self-neglect. Self neglect will be documented in the
narrative section.
Slide 17
Self Neglect Not eating enough to stay well. May be ill May
believe someone is poisoning the food Refuses to bathe or change
clothes. Forgets or refuses medications No heat or electricity
because bills are not paid.
Slide 18
Exploitation is defined as: Misappropriation of property (i.e.
exploitation) means the deliberate misplacement of consumers
property, or wrongful, temporary or permanent use of a consumers
belongings or money without the consumers consent [7.1.13
NMAC].
Slide 19
Exploitation Caregiver uses consumers debit card for their own
purchases People move into the home uninvited and without paying
for rent or utilities Caregiver convinces consumer to sign
timesheet for hours not worked
Slide 20
Deaths are categorized as: Unexpected Death: is any death
caused by an accident, unknown or unanticipated cause.
Natural/Expected Death: is any death caused by a long-term illness,
a diagnosed chronic medical condition, or other natural/expected
conditions resulting in death.
Slide 21
Unexpected Deaths Homicide Suicide Accident Death unlikely to
be attributed to diagnosis/condition Cerebral palsy, mental health
diagnosis, cognitive delay, brain injury, etc
Slide 22
Expected Deaths Hospice Terminal conditions End stage renal
disease Multiple strokes/heart attacks Advanced age (more than 90
years old) Deaths occurring in a facility while in treatment for
disease.
Slide 23
Other Reportable Incidents (ORI) Include: Emergency Services
Law Enforcement Intervention Environmental Hazard
Slide 24
Emergency Services Emergency Services refers to admission to a
hospital or psychiatric facility or the provision of emergency
services that results in medical care which is unanticipated and/or
unscheduled for this individual and which would not routinely be
provided by a community based service provider.
Slide 25
Emergency Services report this: 911 is called and the consumer
refuses to be transported. The consumer gets sick at the store and
the caregiver takes them to the ER. The consumer goes to the ER and
then leaves after checking in but before being seen. The ER
releases the consumer without providing any treatment.
Slide 26
Emergency Services DO NOT report this: The consumer is at the
doctor, gets sick and the doctor sends them to the ER. The consumer
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.
Slide 27
Law Enforcement is defined as: Law Enforcement Intervention is
the arrest or detention of a person by law enforcement, involvement
of law enforcement in an incident or event, or placement of a
person in a correctional facility.
Slide 28
Law Enforcement Police are called to the consumers home because
of a disturbance (even if the consumer is not causing the
disturbance) The consumer is incarcerated. The consumer is picked
up for a bench warrant or parole violation (even if they are
released) The police are called to do a well check (even if they
find them well). The police are called because the consumer is
creating a disturbance.
Slide 29
Law Enforcement Law Enforcement involvement for a caregiver is
NOT an a reportable incident. However, there may be a reportable
incident if The caregiver has harmed or robbed the consumer The
caregiver being detained or incarcerated results in services not
being delivered. The caregiver is also the natural support and is
not available to provide health and safety supports.
Slide 30
Environmental Hazards is defined as: An unsafe condition which
creates an immediate threat to life or health.
Slide 31
Environmental Hazards A fire or flood has created a hazard in
the home Animals are out of control at the home Threatening
services Creating more waste that can be cleaned timely Lack of
repairs that create hazards Lack of water, electricity, heat that
was in place previously Wood heat or hauled water is not considered
a hazard. Holes in the floors Roofs that leak Windows and doors
broken Debris not cleared Foul smells, piles of garbage, standing
dirty water, etc Frayed, broken or trailing live wires Clutter that
impedes normal movement to bathrooms or exits.
Slide 32
Environmental Hazards Drugs, guns and dangerous people Blatant
illegal drug use or visible evidence of the manufacture or sale of
drugs Guns that are not locked up and/or are brandished by the
consumer or others in the home. The consumer or others in the home
threaten, frighten or harm caregivers or others providing
services.
Slide 33
Submitting an Incident Report Reporting abuse, neglect or
exploitation to the MCO and HSD does not relieve a provider of
mandated reporting requirements to Adult Protective Services (APS).
Incident reports must be submitted to the Consumers Managed Care
Organization (United Healthcare or Amerigroup) and HSD/MAD/QAB
within 24 hours of knowledge of the incident. Report all incidents
within 24 hours! If the incident occurs on a weekend or holiday the
incident must be reported on the next business day. Description of
the actual incident should always be provided by the person with
the most immediate knowledge of the incident. All incidents
pertaining to the HSD programs described in this document should be
reported using the Human Services Departments Incident Report form
and are submitted to HSD via FAX at ( 505) 827-3195.
Slide 34
Submitting an Incident Report Agencies that do not comply with
incident reporting requirements are in violation of state statute
and Medicaid regulations, and may be sanctioned up to and including
termination of their provider agreement by an MCO or by the HSD,
Medical Assistance Division.
Slide 35
Who Completes an Incident report? The agency is required to
submit a completed report. The person with the most immediate
knowledge of the incident completes or provides the information for
Section 2. Any staff, employee or consumer may complete an incident
report anonymously.
Slide 36
The Adult Protective Services Act Mandates any person having
reasonable cause to believe an incapacitated adult is being abused,
neglected or exploited shall immediately report that information to
Adult Protective Services.
Slide 37
APS Reporting Requirements Providers shall report to APS:
Abuse, Neglect, Exploitation, And deaths suspected to be a result
of ANE. Abuse, neglect, exploitation, deaths, emergency services,
law enforcement involvement, and hazardous environments to: the
appropriate MCO, (Amerigroup or United Healthcare) and copies to
HSD/MAD/QAB (Report all incidents within 24 hours! (Next business
day in the event of weekend or holiday).
Slide 38
APS REPORTING GUIDELINES First and foremost, always ensure the
safety of the consumer! The New Mexico Adult Protective Services
(APS) Act mandates: Any person having reasonable cause to believe
an incapacitated adult is being abused, neglected, or exploited
shall immediately report that information to the department.
Slide 39
Deaths Reported to APS Deaths that are suspected of being
related to abuse or neglect must be reported immediately to APS.
Deaths that are the result of natural causes and/or are expected do
not need to be reported to APS. If the death occurs outside of a
medical facility, local law enforcement must be notified.
Slide 40
APS Procedure APS 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. Law enforcement must be notified by the person
reporting the incident. When the incident is reported to APS, if
law enforcement has not been notified APS will notify law
enforcement.
Slide 41
Adult Protective Services Statewide Central Intake Incidents
involving suspected/alleged abuse, neglect, and exploitation must
be referred immediately to: Telephone: 866.654.3219 FAX:
505.476.4913
Slide 42
Critical Incident Reporting Flow Chart
Slide 43
HSD Incident Report Form with Numbers and Instructions
Slide 44
HSD Incident Management Sample Form
Slide 45
HSD Incident Management Form
Slide 46
Where Do We FAX Incident Reports? CoLTS C Waiver, Personal Care
Option Program (PCO) Mi Via. APS Fax: 505-476-4913 CPS Fax :
505.841.6691 HSD/MAD/Quality Assurance Bureau Fax: 505-827-3195
Amerigroup Fax: 1-866-920-8354 United Healthcare Fax:
1-866-751-2448
Slide 47
Where Do We FAX Incident Reports? Other programs: DOH/DHI/IMB:
( Developmental Disability Waiver & Medical Fragile) Fax:
(800)584-6057 DOH/DHI/HFLC: ( Licensed Home Health, Assisted Living
Facilities and Nursing Facilities ) Fax: (888)576-0012 * If the
Home Health patient or the Assisted Living resident is a member of
CoLTS C, PCO or Mi Via the report ALSO goes to HSD/MAD/QAB Fax:
505-827-3195.
Slide 48
Fraud Alleged Fraud is reported as follows: Follow the critical
incident reporting process for all cases of Abuse, Neglect and
Exploitation Clearly mark as Exploitation/Alleged Fraud and fax
form to 505-827-3195 You may also send an email to
[email protected] with Alleged Fraud in the subject line
[email protected] or call 505-827-3146.
Slide 49
HSD/MAD/QAB Contact Information If you have questions about any
of the forms or the content of this guide you may send a Fax to:
505-827-3195 You will receive a response to your questions within
48 hours. Please allow additional time for weekends and
holidays.
Slide 50
HSD Incident Management System FAQ/Best Practices What about
multiple reports? What about the consumer who demands that a report
be created about the same thing over and over? (e.g. Accusing a
previous caregiver of stealing) Develop a policy and procedure for
the organization (and shared with consumers) that states multiple
report requests will be reviewed and will be reported to the state
on a monthly basis as one report. Make a documented call/memo to
the consumers consultant, service coordinator or guardian sharing
the issue and requesting assistance for the consumer to understand
the purpose of incident reporting and to assist the consumer to
resolve any issues in services.
Slide 51
FAQ/Best Practices What if the participant does not have a
CoLTS MCO (Amerigroup or United Healthcare)? Do not send the report
to a Salud MCO (Presbyterian, Lovelace, etc.) Send the report to
the Consultant and APS if ANE, and other agencies as defined by the
Incident Management Guide.
Slide 52
FAQ/Best Practices Can I complete a report anonymously? If you
are working for an agency, you must complete the report with your
name and phone number and role with the agency. You may complete a
report anonymously only if you are reporting as a private citizen
who does not have a role in the services for the consumer.
Anonymous reports are difficult to investigate and follow up.
Slide 53
FAQ/Best Practices I know that the state wants the person
closest to the event to complete the report, but sometimes they
cant. What do I do then? Have the person complete the information
for Section 2, then the agency can complete and fax the report.
Call the person and get as much information as possible and
complete the report. Complete the report and provide the persons
telephone number. Complete the report and state how you know what
is reported. You may get a call to explain how you know what
happened. If everything is on the report and it makes sense, it
saves a call.
Slide 54
FAQ/Best Practices What do I do when a consumer calls in to
report dangerous behavior? If a consumer calls and talks about
hurting themselves or others you must have an appropriate and
consistent response. Your agency must have a policy and procedure
for addressing these kinds of calls. This policy must be shared
with the consumer when they enroll in your agency and when you take
the call about the concerning behavior. This policy will describe
the options you will take which may include calling authorities or
a counselor, redirecting to a crisis hot line or other
interventions. The consumer should have a plan in their SSP that
discusses what will occur when they share information about harm.
The consultant must be immediately informed.
Slide 55
FAQ/Best Practices Why doesnt APS put the person into a nursing
home? Why doesnt APS ever call me back? How do I know what APS
found out? APS may be able to assist a vulnerable adult to get a
guardian or may be able to do an emergency support situation. They
can assist the courts to determine competency. They do not make
permanent decisions about peoples lives. APS can tell a reporter of
an incident if the report was received. They may have information
on if it was screened in or out. And if APS needs additional
information or assistance with an investigation the reporting
agency may be involved. APS has very strict procedure about sharing
investigations and outcomes. APS screens incident reports according
to a strict criteria. An report that is screened out may be
screened back in with additional information. An report that is
screened out may be investigated or followed up by other parties;
this is one reason reports are sent to different agencies.
Slide 56
~End~ Questions ?
Slide 57
HSD/MAD Quality Assurance Bureau Nancy Haas, 505-476-7265
HSD/MAD/QAB Fax: 505-827-3195