Incident Reporting Procedure

INCIDENT REPORTING POLICY And INVESTIGATION PROCEDURES

A Four Rivers Incident Report is completed when any of the following situations occur to a staff person or a person served, regardless of whether first aid or medical attention is required:

1. Any type of injury or serious illness; and/or 1. Disagreements resulting in physical or verbal confrontations.

The Incident Report is completed the same day an incident occurs and is disseminated to appropriate sources. The original is placed in the consumer’s file. A copy is maintained in a locked file at the facility, sent to the Case Manager, sent to any other person designated by the individual and a copy must be sent home to the individual’s legal guardian or residential setting (depending on the incident). While FRRS trains all staff on BDDS Incident Reporting and requires them to report to supervisor any suspected incidents to their supervisor or on call person. Only designated staff will submit actual BDDS Reports. For Community Living Division, Coordinator Assistants, Coordinator, QDDP, Nursing Services Coordinator, and Director. For Adult Services, Coordinator, Operations Manager, and Division Director Level can file the report the report.

An Incident Reporting Form contains the following information, date, time, location of incident; who was involved; what led to the incident; a description of what happened; the consequences of the incident; witnesses; who was notified; and follow-up recommendations. Staff are required to provide descriptive and factual information.

All incidents involving persons receiving services or staff shall be recorded, reported and reviewed in order to take actions to avoid similar incidents in the future, make and assess team recommendations and determine any possible pattern of incidents. The incident reporting process is established to ensure the protection of each individual served as well as to guarantee a proactive services planning process. When filling out an Incident Report, every effort should be made to be thorough and accurate detailing only the facts of the incident. Opinion should not be included. When other consumers are involved in the incident, they should only be referred to by their initials. Failure to document reportable incidents involving consumers is considered neglect.

All incidents will be recorded as soon as possible immediately following the incident on the FRRS Incident Report form. This should be submitted to the appropriate supervisor as soon as possible no later than the next business day. The report will be reviewed by appropriate department Coordinator, QDDP, SLCA and NSC. The QDDP or designated Day Services Staff will document and track all incidents in order to determine if there are patterns present and if further action is necessary in order to decrease or extinguish the occurrence of those incidents. (See Incident Tracking Form) The IDT Team will review all incidents for those receiving services and follow up as needed. When/if patterns are discovered, the IDT will meet in order to develop interventions or strategies to prevent future occurrence. If through investigation or analysis a pattern of incidents lead to the suspicion or evidence of abuse, neglect, or exploitation, immediate action will be taken to secure the safety of the consumer. The Seizure Report is used to document incidents involving seizures. The original is placed in the consumer’s file. A copy is sent to the Case Manager, and may be sent home with the individual (depending on the incident). (See attached form)

Alleged cases of abuse and/or neglect are to be documented and reported for children via Child Protection Hotline at 1-800-800-5556 and for adults thru Adult Protection Services at 1-800-992- 6978. (For more information see Four Rivers Abuse, Neglect and Exploitation Policy and Reporting Procedures)

If the incident results in a Workman’s Compensation Claim, the incident must be reported promptly to Four Rivers Health and Safety Coordinator and a copy of the completed Incident Report must be sent to the Regional Office. The First Report of Injury must be completed within the first 72 hours.

A Vehicle Accident Report is required when any Four Rivers company vehicle is involved in an incident or a staff person has an accident in their own vehicle (if they are on company time or transporting a consumer). Vehicle incidents involving company vehicles need to be reported to the Regional Office and Ride Solution Dispatcher as soon as possible after an incident occurs. A completed Vehicle Accident Report needs to be sent to the Regional Office and Ride Solution. When an accident occurs while a staff person is driving their own vehicle they must notify the Regional Office and Base Facility. A completed Vehicle Accident Report and Police Report need to be sent to the Regional office. All DOT Vehicles will follow the Post Accident Standards for Drug Testing. (See attached form)

BDDS Reportable Incidents: Incidents to be reported to BQIS include any event or occurrence characterized by risk or uncertainty resulting in or having the potential to result in significant harm or injury to an individual including but limited to: 1. Alleged, suspected or actual abuse, (which must also be reported to Adult Protective Services or Child Protection Services, as indicated) which includes but is not limited to: a. Physical abuse, including but limited to: i. Intentionally touching another person in a rude, insolent or angry manner; ii. Willful infliction of injury; iii. Unauthorized restraint or confinement resulting from physical or chemical intervention; iv. Rape

b. Sexual abuse, including but not limited to: i. Nonconsensual sexual activity;

Original 9/92 Revised 5/95, 12/97, 11/00 Revised 8/03 Approved 1/15/04 Revised 10/06 Approved 11/30/06 Revised 3/07 Approved 4/19/07 Reviewed 3/10 Revised 9/26/12 approved 10/12 FRRS Incident Reporting Policy and Procedures Page 2 ii. Sexual molestation; iii. Sexual coercion; iv. Sexual exploitation; c. Emotional/verbal abuse, including but not limited to communication with words or actions in a person’s presence with intent to: i. Cause the individual to be placed in fear of retaliation; ii. Cause the individual to be placed in fear of confinement or restraint; iii. Cause the individual to experience emotional distress or humiliation; iv. Cause others to view the individual with hatred, contempt, disgrace or ridicule; v. Cause the individual to react in a negative manner. d. Domestic abuse, including but not limited to: i. Physical violence; ii. Sexual abuse; iii. Emotional/verbal abuse; iv. Intimidation; v. Economic deprivation; vi. Threats of violence from a spouse or cohabitant partner.

2. Alleged, suspected or actual neglect (which also be reported to APS or CPS as indicated) which includes but is not limited to:

a. Failure to provide appropriate supervision, care, or training;

b. Failure to provide a safe, clean and sanitary environment;

c. Failure to provide food and medical services as needed;

d. Failure to provide medical supplies or safety equipment as indicated in the Individualized Support Plan (ISP).

3. Alleged, suspected or actual exploitation (which also must be reported to APS or CPS as indicated)

a. Unauthorized use of the: Original 9/92 Revised 5/95, 12/97, 11/00 Revised 8/03 Approved 1/15/04 Revised 10/06 Approved 11/30/06 Revised 3/07 Approved 4/19/07 Reviewed 3/10 Revised 9/26/12 approved 10/12 FRRS Incident Reporting Policy and Procedures Page 3 i. Personal services;

ii. Personal property or finances; or

iii. Personal identity of an individual;

b. Other instance of exploitation of an individual for one’s own profit or advantage or for the profit or advantage of another.

4. Peer-to-peer aggression that results in significant injury by one individual receiving service, to another individual receiving services.

5. Death (which must also be reported to APS or CPS) additionally, if the death is a result of alleged criminal activity, the death must be reported to law enforcement.

6. A service delivery site with a structural or environment problem that jeopardizes or compromises the health of welfare of an individual.

7. A fire at a service delivery site that jeopardizes or compromises the health or welfare of an individual.

8. Elopement of an individual that results in evasion of required supervision as described in the ISP as necessary for the individual’s health and welfare.

9. Missing person when an individual wanders away and no one knows where they are.

10. Alleged, suspected or actual criminal activity by individual receiving services or an employee, contractor or agent of a provider, when: a. The individual’s services or care are affected or potentially affected; b. The activity occurred at a service site or during services activities; or c. The individual was present at the time of the activity, regardless of location.

11. An emergency intervention for the individual resulting from:

12. Any injury to an individual when the cause is unknown and the injury could be indicative of abuse, neglect or exploitation.

13. Any injury to an individual when the cause of the injury is unknown and the injury require medical evaluation or treatment.

14. A significant injury to an individual that includes but is not limited to: a. A fracture; b. A burn, including sunburn and scalding, greater than first degree; c. Choking that requires intervention including but not limited to: i. Heimlich maneuver; ii. Finger sweep: or iii. Back blows. d. Bruises or contusions larger than three inches in any direction, or a pattern of bruises or contusions regardless of size; e. Lacerations which require more than basic first aid; f. Any occurrence of skin breakdown related to a decubitus ulcer, regardless of severity; g. Any injury requiring more than first aid; h. Any puncture wound penetrating the skin, including human or animal bites; i. Any pica ingestion requiring more than first aid;

15. A fall resulting in injury, regardless of the severity of the injury.

16. A medication error or medical treatment error as follows: a. Wrong medication given; b. Wrong medication dosage given; Original 9/92 Revised 5/95, 12/97, 11/00 Revised 8/03 Approved 1/15/04 Revised 10/06 Approved 11/30/06 Revised 3/07 Approved 4/19/07 Reviewed 3/10 Revised 9/26/12 approved 10/12 FRRS Incident Reporting Policy and Procedures Page 5 c. Missed medication – not given; d. Medication given wrong route; or e. Medication error that jeopardizes an individual’s health and welfare and requires medical attention.

17. Use of any aversive technique including but not limited to: a. Seclusion (i.e. placing an individual alone in a room/area from which exit is prevented); b. Painful or noxious stimuli; c. Denial of health related necessity; d. Other aversive technique indentified by DDRS policy. 18. Use of any PRN medication related to an individual’s behavior.

19. Use of any physical or mechanical restraint regardless of: a. Planning; b. Human Rights committee approval; c. Informed consent. Responsible Parties 1. The provider responsible for an individual at the time of the occurrence of a reportable incident; becomes aware of, or receives information about an alleged incident shall submit an initial report within 24 hours of knowledge. 2. In addition to the provider’s mandatory reporting, any other person may submit an incident initial report associated with any reportable incident. 3. The entity responsible for incident follow-up reports is the individual’s: a. Case manager, when receiving waiver funded services. b. Residential provider’s Qualified Developmental Disabilities Professional (QDDP) when receiving State Line Item (SLI), Supervised Group Living (SGL) or other ICF/MR Services. c. Provider staff when receiving Caregiver Support Services; d. BDDS service coordinator when receiving other services (e.g. Title XX and nursing facilities).

Original 9/92 Revised 5/95, 12/97, 11/00 Revised 8/03 Approved 1/15/04 Revised 10/06 Approved 11/30/06 Revised 3/07 Approved 4/19/07 Reviewed 3/10 Revised 9/26/12 approved 10/12 FRRS Incident Reporting Policy and Procedures Page 6 Ensuring the safety of individuals receiving services 1. When a reportable incident is discovered in which an Individual receiving services is determined to be in danger, the person making the discovery shall: a. Call 911 if indicated; b. Initiate safety actions for the Individual receiving services is indicated and as possible; c. Contact the following and notify them of the situation: d. i.In the supported living settings, the individual’s case manager, or the case management vendor’s 24hr crisis line if the case manager is not immediately available. ii. a manager with the responsible provider company; iii the BDDS District Manager; and iv Adult Protective Services or Child Protective Services, as indicated; and v Individual’s legal representatives.

2. Providers, DDRS staff, and the case management vendor staff shall follow the BDDS Imminent Danger Policy in mitigating the danger to the individual. Initial Incident Reporting to BQIS 1. Within 24 hours of initial discovery of a reportable incident, the reporting person shall file an incident initial report with BQIS using the DDRS approved electronic format available at https://ddrsprovider.fssa.in.gov//IFUR/ In the event of a network malfunction, incident initial reports and incident follow-up reports may be e-mailed to [email protected] or faxed to 260-482-3507. 2. The reporting person shall be descriptive when completing the narrative portions of the incident initial report form, including: a. A comprehensive description of the incident; b. A description of the circumstances and activates occurring immediately prior to the incident; c. A description of any injuries sustained during the incident; d. A description of both the immediate actions that have been taken, and actions that are planned but not yet implemented; and e. A listing of each person (first name, last initial) involved in the incident, with a description of the role and staff title, if applicable, each person involved, Notifying additional entities of incident: 1. Within 24 hours of initial discovery of a reportable incident, the reporting person shall forward a copy of the electronically submitted incident initial report to: a. APS or CPS (as indicated) for all incidents involving: I alleged, suspected or actual abuse: II alleged, suspected or actual neglect; III alleged, suspected or actual exploitation;

Original 9/92 Revised 5/95, 12/97, 11/00 Revised 8/03 Approved 1/15/04 Revised 10/06 Approved 11/30/06 Revised 3/07 Approved 4/19/07 Reviewed 3/10 Revised 9/26/12 approved 10/12 FRRS Incident Reporting Policy and Procedures Page 7 IV death: b. The individual’s BDDS services coordinator c. The individual’s residential provider when receiving residential services; d. The individual’s case manager when receiving services funded by waiver; e. All other service provider identified in the individual’s Individualized Support Plan; and 2. Within 24 hours of initial discovery of a reportable incident, the reporting person responsible shall notify the individual’s legal representative, if indicated

Reportable Incident Follow-up 1. An incident may be closed by BQIS upon receipt and processing. 2. If an incident is not closed upon BQIS’s receipt and processing, BQIS shall forward an email notification to the person responsible for the incident follow-up reporting. 3. The person responsible for the incident follow-up reporting shall: a. Submit an electronic incident follow-up report within 7 days of the incident initial report; b. Continue to submit incident follow-up reports on an every 7 day schedule, until such time as the incident is resolved to the satis faction of all entities; c. Forward copies of each follow-up report to the same entities who received provider internal incident report a copy of the incident initial report. CARF Requirements Sentinel Events CARF requires reporting of sentinel events to the organization’s designated resource specialist at CARF within 30 days of their occurrence. Only designated FRRS staff Rachel Headley and Stephen Sacksteder can access site and report the incident. A form for reporting these will be available online at the CARF website. INVESTIGATION PROCEDURES This purpose of this procedure is to ensure that all incidents that fall into the criteria listed below are investigated fully by an independent team to ensure the continued health and safety of consumers.

This procedure is to be utilized in the event that any of the following should occur. These instances often are what are included on the BDDS Incident Report. If staff are uncertain if an incident requires this process they are encouraged to contact the Health and Safety Coordinator for confirmation.  injury of unknown origin;  alleged or suspected abuse, neglect, exploitation, or mistreatment;  significant injury including: a fracture, a burn greater than first degree, choking that requires intervention;  suspected or actual criminal activity by a staff member, employee or agent of another provider or an individual receiving services;  inadequate medical treatment (failure to provide necessary emergency medical services); or

If an incident has been identified as requiring an investigation, the Coordinator or SLCA will notify the Health and Safety Coordinator or designee immediately. The Residential Investigation Team will be comprised of Nursing Services Coordinators, QDDPs, as well as the Health and Safety Coordinator, who serves as the administrator of this process. The Adult Services Investigation Team will include Service Coordinators, Division Directors (as appropriate), Information Services Director, as well as the Health and Safety Coordinator, who serves as the administrator of this process. There may be instances where both teams will be involved in the same investigation process. Team members will not be involved in the investigation process of an incident that directly impacts their location.

The team will then review the incident through the following process:  Following immediate notification of the incident, the Health and Safety Coordinator will contact the other team members and determine an appropriate course of action for the investigation to be completed. If in immediate jeopardy the team will take immediate action (i.e., suspend staff, etc.).  The team will then convene in the manner deemed most appropriate for each incident.  The team will be responsible for completing the investigation checklist/worksheet. The results of the investigation must be available within 5 days of the incident.  The team will then follow-up with the appropriate Coordinator and/or SLCA (if appropriate) to make recommendations in order to prevent future incidents.  The investigation worksheet/checklist along with any other investigation materials will be filed in Regional Office with the BDDS and/or Four Rivers internal incident report. Each facility will maintain a master book at their main facility.

REPORTABLE INCIDENT ANALYSIS The Health and Safety Coordinator conducts a monthly analysis of BDDS Incident Reports. Recommendations to reduce the risk of future incidents, trends and actions taken are documented in monthly reports and submitted to appropriate staff, Executive Director, Division Director, QDDP, FRRS Behavioral staff, and Group Home Coordinators’ review of recommendations and actions taken will determine their effectiveness.

STAFF TRAINING The Incident Reporting Policy and Investigation Procedures are reviewed annually for the purpose of staff training and upon hire during Orientation period as a Core Training. As additional training on this topic is available when needed. The training will have competency based testing and a system of documenting each training with a Training Evaluation form. The material or class will be developed or taught by a trainer has sufficient education, expertise, and knowledge of the subject to achieve listed outcomes required.

Original 9/92 Revised 5/95, 12/97, 11/00 Revised 8/03 Approved 1/15/04 Revised 10/06 Approved 11/30/06 Revised 3/07 Approved 4/19/07 Reviewed 3/10 Revised 9/26/12 approved 10/12 FRRS Incident Reporting Policy and Procedures Page 9 POLICY REVIEW This policy may be revised as needed but will be formally reviewed every year. Input will be solicited in various direct service staff and coordination team meetings and presented to the Health and Safety Coordinator. This input will be submitted to and discussed by Division Directors. Recommendations will be submitted to the Four River’s Board of Directors for approval. This policy was adapted from: 1* Employment and Community Services CARF Standards Manual, (1996, 1998, 2001, 2004, 2007,2010,2012), Tucson, AZ 2* Medicaid waiver – Support Services Waiver Manual, Section 14 Incident Reporting, (3/28/02) 3* Policy and Procedure Manual, Bureau of Developmental Disabilities Services, Incident Reporting, (6/11/02) 4* DDARS Provider Standards, Supported Living Services and Supports, Title 460, Rules 1-34, 460 IAC 6-9- 5, 5* DDRS Policy Number BQIS 460 0301 008 3/1/2011 6* DDRS Policy Number BQIS 460 0000 041 3/1/2011