Serious Reportable Incident Reporting Procedure
Reporting Responsibilities
Just as a variety of individuals associated with a waiver service provider may be involved in an alleged SRI they may also be a witness of such actions. The requirements for reporting this event also takes into account that the actual witness is obligated to inform his/her supervisor. In such cases the supervisor may be the one to report the alleged Serious Reportable Incident to the QMS.
In situations where only a family member or other informal support has witnessed the SRI or when there were no witnesses to the incident, the waiver service provider employee, who was made aware of the incident or his/her supervisor is responsible for filling out the reporting form and is considered to be the discoverer of the incident.
Regardless of who reports the incident, the QMS will assign the responsibility for the investigation to the waiver service provider agency whose employee was allegedly involved. If the incident does not involve a waiver service provider's employee, the QMS has the discretion to assign the responsibility of the investigation to any of the participant's waiver service providers or to undertake the investigation themselves.
If the QMS is concerned that the waiver service provider responsible for investigating the SRI is not in a position to conduct an objective, thorough investigation, the QMS has the discretion to assign the responsibility of the investigation to another provider or to undertake the investigation themselves. QMS must notify DOH WMS for technical assistance when there are any concerns regarding the investigation of a SRI.
Note: In the event an employee of an Assistive Technology, Community Transitional Services (CTS), Congregate Home and Delivered Meals, Environmental Modification or Moving Assistance provider witnesses an incident or has any concerns involving the participant, that employee must notify his/her agency's supervisor. The supervisor is responsible to contact the Service Coordinator (SC) to report the alleged incident.
All providers of Assistive Technology (AT), Community Transitional Services (CTS), Congregate Home and Delivered Meals, Environmental Modification (E-mods) and Moving Assistance must inform all subcontractors used of their responsibility to report any witnessed or suspected incident involving a waiver participant to the waiver service provider supervisor. Upon notification by any subcontractor, these waiver service provider supervisors must proceed with the same SRI reporting protocol as in the paragraph immediately above.
In the event an incident is witnessed by an employee of a Home Visits by Medical Personnel provider, that employee must notify the SC directly.
Upon notification by any of these providers, the SC becomes the 'discoverer' of the incident and is responsible to initiate the reporting process with QMS.
Note: Providers of AT, E-mods, Congregate and Home Delivered Meals and Home Visits by Medical Personnel will not be assigned the responsibility of investigating any allegations of a SRI unless they provide other services for which they are responsible for investigating incidents.
Procedure
Note: All forms used in the Serious Reportable Incident (SRI) procedure can be found in Appendix E - forms SRI.1 to SRI.6 of this Program Manual.
Within two (2) hours of discovering a SRI has occurred, the discovering waiver service provider, SC, RRDS or DOH must notify the QMS via telephone or email, then complete and forward the "Initial Report" form. A copy of this form must be sent to the RRDS and SC by the discoverer.
If the incident involves any type of abuse listed or the death of a participant, the QMS must notify DOH WMS by the next business day via phone, also providing a copy of the "Initial Report" form. Upon request of DOH WMS, QMS will provide copies of any other forms related to the incident to DOH WMS.
When appropriate, any waiver service provider or waiver entity may contact Adult Protective Services (APS) related to an alleged incident involving a waiver participant at any time during the Serious Incident Reporting process. In addition, a waiver service provider, SC, RRDS or QMS must assure the participant is reminded of his/her right to notify the police as appropriate. The QMS will assure that any known contact made by the provider with APS or with the police has been appropriately documented on the "Initial Report", "24-Hour Provider Report", "Provider Follow-Up Report", or subsequent "Provider Follow-Up Reports".
Within twenty-four (24) hours of discovery, the reporting waiver service provider must complete and send the "24-Hour Provider Report" to QMS. The QMS will forward a copy of the report to the RRDS and SC.
Note: If the SC is alleged to be involved in the incident, the "24-Hour Provider Report" is sent to the Service Coordination Supervisor.
Note: If the 'discoverer' of the incident is DOH WMS or RRDS, the QMS will assign completion of the "24-Hour Provider Report" to a waiver service provider.
Upon receipt of the "24-Hour Provider Report" form, the SC must contact the participant and/or legal guardian and informs him/her that an investigation is under way. In addition, the SC must notify any other waiver or non-waiver provider currently involved in the Service Plan (SP) when there is visible evidence of injury to the waiver participant or when the incident or response to the incident may impact services or activities. Consideration of the individual's privacy should be balanced against the need to notify only service providers who need to know for the purpose of service delivery. Contact with the waiver participant and/or legal guardian and/or other waiver service providers must be documented using the "Service Coordinator 24-Hour Notification Report". The SC sends this report to the QMS.
Note: If the SC is alleged to be involved in the incident, the Service Coordination Supervisor is responsible for contacting the participant and following Step #3 above.
Note: All waiver providers must assure that during the investigation, if the person alleged to be involved in the incident directly serves the participant (e.g. the SC), he/she must not continue to serve the participant. The agency's supervisor must work with the participant to assure selection of an alternate individual to work with the participant. In addition, the participant must be offered the choice to select a different provider if one is available.
Within twenty-four (24) hours of receiving the "24-Hour Provider Report" form, the QMS will review the form and then complete the QMS "Initial Response" form. The QMS assigns an incident number to the incident and enters it onto the form. This number must be included in all future reports and correspondence relating to the incident.
- Assigning a Number to an Incident:
Each incident number consists of four sets of numbers, each series being separated by a dash ( - ):
- a two digit number indicating the Recipient/Exception code (e.g. code 60 for NHTD waiver participant);
- a four digit number indicating the year of the incident (e.g. 2008);
- a two digit number indicating the RRDC region (e.g. 09); and
- a three digit number assigned to the specific incident.
Numbers start at 001 for each RRDC region and continue in consecutive order from January to December.
Each RRDC Region is assigned a two-digit code number as follows:
- 01 Long Island
- 02 New York City
- 03 Unused
- 04 Lower Hudson Valley
- 05 Capital Region
- 06 Adirondack
- 07 Syracuse
- 08 Southern Tier
- 09 Rochester
- 10 Buffalo
Example: An incident in the NHTD waiver occurred in the Hudson Valley region in 2008 and is the 7th incident reported to that region. The QMS for that region creates an incident number as follow: 60-2008-04-007.
- Classification and Category Verification:
The QMS will document on the QMS "Initial Response" form acceptance of the original classification or, if indicated, the re-classification of the incident.
Note: In the event the QMS determines that the incident does not meet the definition of a SRI and re-categorizes the incident as a Recordable Incident, this must be noted on the QMS "Initial Response" form. In this instance, the case is considered CLOSED. The QMS also completes the QMS "Status Report" form.
The QMS will notify the participant via telephone that the incident has been closed and the reason why. This contact must be documented by the QMS "Status Report" form.
QMS provides a copy of the QMS "Initial Response" and the QMS "Status Report" forms to the reporting agency, RRDS and Service Coordinator.
- Assigning Investigation
QMS will determine which waiver service provider will be responsible for conducting the investigation and will contact the provider agency to discuss the provider's plan for investigating the incident. The QMS will provide technical support to the waiver service provider and may request assistance from DOH in the process, if necessary. The QMS will document contact on the QMS "Initial Response" form and provide the dates of the expected seven (7) calendar day and thirty (30) calendar day Follow-Up Reports. A copy of the QMS "Initial Response" form is provided to the waiver service provider assigned to the investigation, the reporting provider, RRDS and SC by QMS.
Note: Providers of Assistive Technology, Environmental Modifications, Congregate and Home Delivered Meals and Home Visits by Medical Personnel will not be assigned the responsibility of investigating any allegations of a Serious Reportable Incident unless they provide other services for which they are responsible for investigating incidents.
- Assigning a Number to an Incident:
QMS will forward the QMS "Initial Response" form and the "24-Hour ProviderReport" form to the investigating waiver service provider, sending a copy to the discovering provider (if different from the investigating waiver service provider),RRDS and Service Coordinator.
The investigating provider must assign an appropriate individual from the waiver service provider agency or may choose to contract with another agency to conduct the investigation. At the same time, the investigating provider must notify its Serious Incident Review Committee (SIRC) (refer to the section below - Provider's Serious Incident Review Committee) that there has been an allegation and the investigation has been assigned (refer to "Investigation of Serious Reportable Incidents" in the section to follow).
Within seven (7) calendar days of receiving the QMS "Initial Response" form and the "24-Hour Provider Report" form, the investigating waiver service provider must complete and submit the "Provider Follow-Up Report" to the QMS including all formal investigating agency reports, interview statements, and any contact made with the SIRC. The QMS must forward a copy of the "Provider Follow-Up Report" to the RRDS and the SC.
Within seven (7) calendar days of receiving the "Provider Follow-Up Report", the QMS will make the decision whether to close the case or leave it open for further investigation, using the RRDS for consultation as needed. The QMS will complete the QMS "Status Report" indicating whether the case:
- is re-classified (with explanation);
- remains open (and the reason why); and/or
- is closed.
If left open for further investigation, the investigating waiver service provider must continue the investigation process and prepare information for submission of the completed "Provider Follow-Up Report" (30-day).
The QMS must send a copy of the report to the RRDS, the SC and the investigating provider.
Within thirty (30) calendar days of receiving the original QMS" Initial Response" and the "24-Hour Provider Report" forms, the investigating waiver service provider must submit the next "Provider Follow-Up Report" to QMS for review, with copies of all reports, statements, and supporting documentation attached. The QMS will forward the report to the RRDS and the SC.
Within seven (7) calendar days of receipt of the "Provider Follow-Up Report" form, the QMS will make the decision whether to close the case or leave the case open for further investigation, using the RRDS for consultation as needed. The QMS will complete the QMS "Status Report" indicating whether the case:
- is re-classified (with explanation);
- remains open (and the reason why); and/or
- is closed.
The QMS must send a copy of the report to the RRDS, the SC and the investigating provider.
If further investigation is deemed appropriate by the QMS, the "Provider Follow-Up Report" must continue to be submitted by the investigating waiver service provider monthly by the anniversary date of the discovery of the incident until the QMS determines the case to be 'closed'. A copy of each report is forwarded to the RRDS and SC by QMS. When the case is deemed closed, QMS must complete the QMS "Status Report", sending a copy to the RRDS, the Service Coordinator and the investigating provider.
If the case is re-classified, the investigation must continue under the same protocol as if open, until the QMS can determine that the investigation has been completed and the case can be closed.
Once the investigation is closed, the QMS must notify the participant via telephone that the investigation has been completed. Although details of the investigation are not disclosed, the final outcome is provided to the Participant/Legal Guardian. This contact is documented by the QMS on the QMS "Post-Investigation Follow-Up Contact With Participant" form.
Any further contact with the participant will be made at the discretion of the QMS depending on the type and outcome of the investigation. When indicated, QMS will consult with the RRDS and/or DOH WMS to determine what, if any additional contact needs to be made. The QMS will document all contacts on the QMS "Post- Investigation Follow-Up With the Participant" form.
The QMS must maintain an Incident database, tracking all incidents reported. The QMS must also maintain all documentation related to the SRI in a separate file.
The RRDS must also maintain copies of all documentation related to SRI in a file separate from the participant's record and easily available to DOH WMS upon request.
If at any time during the procedure for SRI a waiver service provider does not comply with time frames outlined for reporting and/or has failed to comply with necessary documentation requirements, the QMS will notify DOH WMS. This may include, but is not limited to, the waiver service provider's failure to submit any of the required documents to the QMS (e.g. the seven (7) or thirty (30) day "Provider Follow-Up Report", etc). DOH WMS will determine what actions must to be taken including the need to place the waiver service provider on Vendor Hold and if so, will a send the Notice of Vendor Hold to the provider agency's Executive Director. The Notice of Vendor Hold will outline the need for immediate attention to the incident and a plan of action by the waiver service provider which will include information to correct the situation and ensure such delays do not occur in the future.
If there are extenuating circumstances as to why the SRI procedures were not followed, a representative from the waiver service provider agency's administration is required to contact the QMS prior to the procedural deadlines to discuss the situation. The QMS will make the determination whether the situation warrants an extension of the policy and will notify DOH WMS of all such decisions.
When the waiver provider agency submits all necessary SRI documentation and a plan of action approved by DOH WMS and the QMS, the Vendor Hold process will be stopped via a letter from DOH WMS.
Should the waiver provider agency fail to submit the necessary SRI documentation and an acceptable plan of action within seven (7) calendar days of the Notice of Vendor Hold, the QMS will notify DOH WMS. DOH WMS will issue a Notice of Disenrollment to the waiver provider agency Executive Director indicating that due to continued non-compliance with the SRI Policy and Procedure, the waiver service provider will be disenrolled from the NHTD waiver sixty (60) calendar days from the Notice date.
If at any time during this process, the provider agency complies with all policy and procedures, as related to SRI, and submits an acceptable plan of action approved by DOH WMS and the QMS, DOH WMS will determine whether the disenrollment process may be stopped and will send written notification to the waiver service provider's Executive Director.
