Critical Incident Reporting 525-05-42

(Revised 7/1/21 ML #3627)

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IM 5442

Critical Incident

A critical incident is any actual or alleged event or situation that creates a significant risk of substantial or serious harm to the physical or mental health, safety or well-being of any client receiving HCBS.

In order to assure the necessary safeguards are in place to protect the health, safety, welfare of all clients receiving HCBS, all critical incidents (as defined in this chapter) must be reported and reviewed (as described in this chapter). The goal of the incident management system is to proactively respond to incidents and implement actions that reduce the risk of likelihood of future incidents.

Reportable incidents

Abuse (physical, emotional, sexual), neglect, or exploitation;
Rights violations through omission or commission, the failure to comply with the rights to which an individual is entitled as established by law, rule, regulation, or policy;
Serious injury or medical emergency, which would not be routinely provided by a primary care provider;
Wandering or elopement;
Restraint violations;
Death of a client and cause (including death by suicide);
Report of all medication errors or omissions; and
Any event that has the potential to jeopardize the client’s health, safety or security if left uncorrected.
Changes in health or behavior that may jeopardize continued services.
Illnesses or injuries that resulted from unsafe or unsanitary conditions.

HCBS Case Manager will follow up with all reported critical incidents.

If HCBS Case Manager has first-hand knowledge of a critical incident, follow incident reporting requirements.

If the case involves abuse, neglect or exploitation, a formal VAPS (Vulnerable Adult Protective Services) referral will be initiated according to ND Century Code 50-25.2-03. VAPS will be responsible for independent review and follow up.

If the incident involves a provider, the complaint protocol will be followed to determine the next steps, which may include involving law enforcement.

Incident reporting requirements

Any paid provider or family member who is with a client, involved, witnessed, or responded to an event that is defined as a reportable incident, is required to report the critical incident.

A General Event Report (GER) is a Critical Incident Report (CIR) in the Therap case management system.

As soon as a paid provider or paid family member learns of a critical incident involving a client, the incident must be:

Reported to the HCBS Case Manager and
Complete a Critical Incident Report (CIR) using the General Event Report (GER) within Therap.

The completed CIR is to be submitted within 24 hours of the incident.
If the QSP does not have access to Therap, the GER offline forms will be completed and submitted to the HCBS case manager.
1. The offline forms can be accessed here.
2. The GER Event Report along with the GER Event Type form (e.g. medication error, injury, etc.) are to be completed and submitted together.
The HCBS Case Manager and program administrator will receive the incident report once submitted for review in Therap. If the GER offline form is used, the HCBS Case Manager will fax the form to (701) 328-4875 or email: dhshcbs@nd.gov. The program administrator will then enter the GER Event Report and Event Type into Therap.

Examples

Example 1: If a client falls while the QSP is in the room but the client didn’t sustain injury or require medical attention, a critical incident report is not required.

Example 2: If a family member informs the case manager that a client is in the hospital due to a stroke, a critical incident report is not required because the case manager nor QSP witnessed or responded to the event.

Example 3: If a QSP comes to a client’s home and the client is found on the floor and the QSP calls 911 so the client may receive medical attention, a critical incident report is required because the client required medical attention AND the QSP responded to the event (fall).

Example 4: If a QSP is present while the client is participating in illegal activity (e.g. drug use), a critical incident is required as the behavior is jeopardizing services.

Example 5: If the QSP finds bed bugs in the client’s bed and notices the client has bug bites resulting in the need to seek medical attention, a critical incident would be required as this is an unsanitary condition resulting in illness or injury.

Department Responsibilities

The department will submit a medical case incident report into the ND Risk Management Incident Reporting system received from the HCBS case manager within 24 hours of receiving the report.

The program administrator will enter GER offline reports into Therap within 24 hours of receiving report or 1 business day.

The department will hold quarterly critical incident team meetings to review all critical incident reports for trends, need for increased training and education, additional services, and to ensure proper protocol has been followed. The team consists of the ND DHS Aging Services Division Director, HCBS program administrator(s), HCBS nurse administrators, Vulnerable Adult Protective Services (VAPS) staff, LTC Ombudsmen, and the DHS risk manager.

The Department of Justice (DOJ) agreement coordinator (Aging Services Division Director) is responsible to report critical incidents as described in the settlement agreement to the DOJ and the subject matter expert (SME) within 7 days of the receipt of the critical incident.

Remediation Plan

A remediation plan is required to be developed and implemented for each incident except for death by natural causes as required by the DOJ and the Aging Services Department. The department will be responsible to monitor and follow up as necessary to assure the remediation plan was implemented.

The remediation plan will include corrective actions taken, a plan of future corrective actions, and a timeline to complete the plan if applicable. The HCBS case manager and program administrator are responsible to follow up with the QSP to ensure the remediation plan is acceptable.