POLICY AND PROCEDURE- INCIDENT REPORTING
Applicable standard or regulation:
(10 C.C.R. 2505-10 Section 8.608.6)
Applicable standard or regulation: Chapter II, Part 3, Section 3.1 6 CCR 1011-1 (10 C.C.R. 2505-10 Section 8.608.6) 6 CCR 1011-1 Chap 26 Agency reporting 6.10, chapter 26
Incident/accident reporting provides a systematic way of reporting all incidents and assures that follow-up is initiated and carried out. Incident/accident reporting also provides a way for the agency to determine whether there are any patterns to incident or accidents which may be preventable by making changes in the way services and supports are provided to individuals.
Incidents which must be recorded, reported and reviewed are:
- Injury to client
- Injury to provider
- Lost or missing person
- Unusual Behavior
- Medical emergency- client
- Seizure of unusual nature
- Aggression towards others
- Aggression towards self
- Hospitalization- client
- Death- client
- Error in medication administration
- Restraint use
- Safety Control Procedure
- Emergency Control Procedure
- MANE, Allegations of abuse, mistreatment, neglect or exploitation
- Client's property stolen
- Theft / vandalism BY client
- Subpoena / Court Appearance
- Incident of concern
- Appearance that is concerning
- Concern ABOUT provider/professional
- All incidents are to
reported in writing within ONE hours of end of incident (TLOG WILL WORK WITH A SUMMARY IF
THERE IS NOT YET TIME TO DO A FORMAL GER) when HOWEVER, CRITICAL OCCURANCES MUST BE
REPORTED WITHIN 60 MINUTES BY via
phone call WITH A TEXT FOLLOWUP to the emergency line.
- The agency has 24 hours or till the end of the next business day to respond and file needed responded regarding the incident report.
- Complete a GER within 12 hours with complete details and make any mandatory reports. *Remember, memories fade and change as time goes, a report will be more accurate the sooner it is written)
In the instance of MANE, for children and adults reporter must also follow procedure for reporting as designated in state training related to: Part 3 of Article 3 of Title 19, C.R.S. and Article 3.1 of Title 26, C.R.S. All providers complete the state training and have at least annual reviews regarding policies and procedure related to MANE
- The following must be included on the incident/accident report form.
- The date of the report
- The reporting providers name, specialty, contract information, and provider's business name
- Agency provider works with
- Name of person the incident report is for
- DOB of the person the incident report is for
- Legal Guardian's name, address, phone, and county
- Other people involved, including witnesses DO NOT USE OTHER CLIENT'S NAMES, IF OTHER CLIENTS ARE INVOLVED OR WITNESSED THEN ONLY USE THEIR CLIENT ID NUMBER
- Service Coordinator / Case Manager
- Date of incident
- Type of incident
- Did you observe the incident
- If no, how did you obtain the information
- Describe incident, situation, including the events leading up to the incident, detailed information regarding any physical injuries, property dames, how long the incident took play, if there Is as a restraint, what restraint techniques were used and how long the restraint took place
- Is there any relevant history that should be known
- Is there a behavior support plan in place already for the person who the incident report is for
- Is the this incident likely to occur again
- Any recommendations or input
- Record any consequences to services due to this incident or action plan from contractor perspective
- Include any supporting documentation in the client's clinical documents file and list the names of the files.
- Supporting documents are pictures, videos, other forms you may have completed, police records, body charts you used to detailed bodily injury, etc.
- Persons you notified
- Case File Analysis
- Care Conference
- Follow Up Actions Taken
- If the agency has questions regarding an event being reportable Angels may call Occurrence Reporting from Health Facilities. Inquires will be documented.
Serious incidents/accidents include THESE ARE ALL EXAMPLES OF CRITICAL INCIDENTS:
Significant injury beyond basic first aide
Adverse Medical/health outcome
Exploitation of loss in excess of $300
Trend of incidents requiring investigation
Requires immediate emergency medical treatment to preserve life and or limb
Results in emergency admission to the hospital
Victim of a serious crime
Person receiving services is the victim of a serious crime (could result in felony conviction and or sentence resulting in jail time.)
Crime committed by another person receiving service, someone in the community, guardian, or family member.
Serious criminal offense by person
Committed by the person receiving services
Violation of parole or probation potentially resulting in revocation of parole/probation.
Media interest or involvement
Person receiving services immediate location is not known
Safety of the person is at serious risk, such as loss of home
May pose a risk to the general public
Other exacerbating circumstances exist that clearly increase the seriousness of the risk.
Location of the person is unknown for (8) or more hours regardless of level of risk.
Follow-up to an incident report:
The agency will conduct review of incidents individually:
- We will request an action plan put in place to prevent future reoccurrence if possible
- We will offer relevant support to client and family if appropriate and within boundaries
- We will offer relevant support to providers if appropriate and within boundaries
- We will hold a care conference if needed to discuss plan, support, or change in placement
- Determine if report needs to be send to another agency such as case management, family, or the state department for occurrence reporting
- We will determine a follow up schedule for review of incident if appropriate
Emergency discharge required:
If an client needs to be released due to an incident report reflecting that the client's, provider's, or community's health, welfare, or safety is jeopardized be the continuous of care the client, case will be notified within 48 hours. For HCA clients, CDHPE will also be notified.
For HCA clients the agency will notify CDHPE BEFORE discharge is initiated discharge any client who needs and wants service to continue and there are no known paid transfer arrangements to protect the consumer’s health, safety or welfare or the providers, or the communities.
- The Agency will follow up within 24 hours or the next business day when incident is critical or within 72 hours when it is not with:
- The agency administrator
- Community Center Board
- The coroner if a death has resulted in a questionable nature
- For Imagine: all critical incidents should be routed within 24 hours to firstname.lastname@example.org
- Parent or Guardian as applicable
- Any person specifically requested in the client’s consent to share to receive notification such as these.
- For HCA clients the report will also be sent to the CDHPE designated representative
- If the incident
involved an agent being accused of one of the following a report must be
filed with CDPHE. Supporting literature can be found here: https://www.colorado.gov/pacific/sites/default/files/HF_Home-Based-Service-Agencies_0.pdf
- Physical abuse
- Sexual abuse
- Verbal abuse
- Brain injury
- Diverted Drugs
- Malfunction or misuse of equipment
- Misappropriation of patient property
- Missing persons
If the incident is logging known and ongoing challenges then unless assistance is required or it is of a critical nature, reports will remain within the agency. For example, if a client bumps into things or self harms (with only minor first aide needed) on a regular basis we will log this information but separate reports will not be sent unless something changes or assistance is needed. If this type of incident is common talk to the agency about alternative ways to document.
Analysis of Incident Reports
- The provider and owner will analyze information from incident reports to identify trends and problematic practices which may be occurring in specific services and take corrective action to address problematic practices. Trends will be completed every 90 days.
Trends will be collected by:
- Type of Incident
- Program / Service
Published 12/29/2016 by Serena Akinahew
1/12/2017, added detailed checklist, time lines, expanded reasons for incident reports by Serena Akinahew
1/14/2017, detailed procedure to include more detailed timelines, and updated notification information by Serena Akinahew
1/15/2017, detailed what needed to be included on an incident report and who is responsible
2/8/2017, Imagine! details added
Nov 2018 refreshed