Health Home Monitoring: Reportable Incidents Policies and Procedures HH0005

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Policy Title: Health Home Monitoring: Reportable Incidents Policies and Procedures
Policy number: HH0005
Effective date: April 15, 2017
Last Revised: November 15, 2022
Supersedes: Health Home Monitoring: Reportable Incidents Policies and Procedures and Reporting Timeframes Policy #HH0001 (4/15/17)
Approved by:

Applicable to: This policy pertains to adults and children/youth enrolled in the Health Home Program.

Purpose:
This policy defines the requirements for Health Homes (HH), including Children's Home and Community Based Services (HCBS) providers, to identify, report, receive, review, resolve, and record Reportable Incidents, including a continuous quality improvement process to track and identify trends to reduce risk and minimize the potential for future occurrence of the same or related incidents.

A reportable incident is an event involving a member, which has, or may have, an adverse effect on the life, health, or welfare of the member. A list of reportable incidents can be found below.

Health Homes must have a system in place to effectively manage Reportable Incidents for their members. Health Homes must have policies and procedures in place that clearly define what is reportable and the responsibility for managing reportable incidents, including assurance that appropriate and timely intervention(s) occur and corrective action is implemented.

Policy:
The Department will require that HHs have policies in place to handle any reportable incidents in compliance with the Health Home Standards outlined in the State Plan Amendment. The Department will work with the HH to ensure the HH establishes policies and procedures to:

  • Identify, document, report, and review individual incidents within timelines specified in this policy;
  • Enter Reportable Incidents within the Incident Reporting and Management System (IRAMS);
  • Evaluate individual incidents against HH and Care Management Agency (CMA) policies and procedures to confirm quality care coordination activities were provided;
  • Review individual incidents to identify appropriate preventive or corrective action was taken to ensure health and safety of the member;
  • Identify incident patterns and trends through the compilation and analysis of incident data;
  • Review incident patterns and trends to identify appropriate preventive or corrective action, technical assistance, or training;
  • Implement preventive and corrective action plans; and,
  • Identify policy and or procedure changes.

The process for reporting an incident is as follows:

  • Health Home (HH) policies and procedures must mandate that the Case Manager (CM) inform the HH of a reportable incident within 24 hours of notification or discovery
  • The HH must inform the Department within 24 hours of notification from the CM
  • The Department will review the incident reported by the HH and make recommendations, if necessary, to ensure that the Health Home's reportable incident policy is appropriate and in compliance with established HH Standards
  • The Department will require HHs to submit, on a quarterly basis, the total number of reports in each of the categories noted on the Health Home Reportable Incident Form, due by the 10th business day after the end of the quarter:
    • January - March, due April
    • April - June, due July
    • July - September, due October
    • October - December, due January

HHs must have a quality assurance process in place to ensure that CMAs comply with their policies and procedures.

If a HH member is also receiving services in a program under the jurisdiction of another State agency (e.g., Office of Mental Health (OMH); Office of Alcoholism and Substance Abuse Services (OASAS); Office for People With Developmental Disabilities (OPWDD); or Office of Children and Family Services (OCFS)) which has stated incident, abuse, neglect, or maltreatment reporting requirements, this policy does not relieve the obligation to report in accordance with such regulations. Such reporting is not the responsibility of the HH, although the organization should cooperate as necessary.

For HH members receiving court-ordered assisted outpatient treatment (AOT), HHs shall ensure CMAs comply with the requirements of AOT Health Home Plus (HH+), which states the CMA shall comply with all reporting requirements of the AOT Program as established by the Local Government Unit (LGU). Such requirements include the reporting of significant events. Though the LGU may have primary responsibility to investigate significant events involving an AOT individual, the HH shall cooperate as necessary.

The Protection of People with Special Needs Act requires persons who are Mandated Reporters under that Act to report abuse, neglect and significant incidents involving vulnerable persons to the Vulnerable Persons' Central Register (VPCR) operated by the NYS Justice Center for the Protection of People with Special Needs. For additional information and requirements, please see the: NYS Justice Center website.

N.Y. Social Services Law 413 - Persons and Officials Required to Report Cases of Suspected Child Abuse or Maltreatment require Mandated Reporters to report suspected child abuse or maltreatment to the New York State Office of Children and Family Services maintains the Statewide Central Register of Child Abuse and Maltreatment (SCR, also known as the "hotline") for reports made pursuant to the Social Services Law.

Care Management Agency Reporting Responsibilities

HH policies and procedures must mandate that the CMA inform the HH of a reportable incident within 24 hours of notification or discovery (or where applicable, by the next business day), including the known facts and circumstances of the incident, the member's enrollment date, last contact date and type, and current location, if known.

The following is a list of reportable incidents. Please reference the "Definitions" section in the appendix for definitions of each of these incident types.

  1. Allegation of abuse, including:
    • Physical abuse
    • Psychological abuse
    • Sexual abuse/sexual contact
    • Neglect
    • Misappropriation of member funds
  2. Suicide attempt
  3. Death
  4. Crime Level 1
  5. Missing person
  6. Violation of Protected Health Information (PHI)

Health Home Serving Children (HHSC) - Children's Home and Community Based Services (HCBS)

The HCBS Children's Waiver has additional reporting requirements; therefore, for children/youth receiving HHSC (regardless of HCBS enrollment), additional reportable incidents are:

  • the use of restrictive interventions, including restraints and seclusion, and
  • exploitation

The above are considered reportable incidents and should be reported following the same process as other reportable incidents defined within this document.

Health Home Reporting Responsibilities

The HH must inform the Department within 24 hours of notification from the CMA (or where applicable, by the next business day), any reportable incident listed above, along with initial findings utilizing the Incident Reporting and Management System (IRAMS) housed within the Health Commerce System (search for the "Incident Reporting and Management (IRAMS) application) or by using the following link: Health Commerce System.

At a minimum, the HH must immediately review the facts and circumstances of the current incident with the CMA, along with all pertinent information and incident reports. The HH is responsible to ensure that the CMA followed all policies, standards, and reporting requirements (Mandated Reporting). The HH will provide oversight and direction to the CMA to ensure member safety and well-being as well as program integrity, overall programmatic expectations, and compliance with Health Home Standards. The HH will provide instruction, directions, training, technical assistance, and or require additional gathering of information as needed.

For Health Home Serving Children, this oversight and direction to the CMA will be completed within thirty days (30 days) of receiving the incident report in the IRAMS.

The Department will review the incident reported by the HH and make recommendations, if necessary, to ensure that the Health Home's reportable incident policy is appropriate and in compliance with established HH Standards.

Effective April 1, 2021, HHs will no longer be required to submit quarterly reports to the Department related to reportable incidents. However, HHs must continue to monitor and evaluate incident reports to identify patterns and trends, implementing preventive and corrective action plans, as warranted. HHs can access information using the Report function within IRAMS. The HHs and the Department will utilize IRAMS reports to develop, enhance, and/or address program needs.

Additional information such as User Guides and FAQs related to the Incident Reporting and Management System (IRAMS) can be accessed via the Health Home program website

Other Notifications:

Health Home Care Managers should be mindful that other entities should receive these reports and collaborate with all entities to ensure safety and well-being of the member, I.e., Law Enforcement, and Justice Center and all professionals including HH CM as Mandated Reporters.

Resource List

NYS Justice Center/Vulnerable Persons Central Registry 855-373-2122 https://www.justicecenter.ny.gov/
NYS Adult Home Hotline 866-893-6772 /contact/doh800
.htm
NYS Nursing Home Complaint Hotline 888-201-4563 https://apps.health.ny.gov/surveyd8/nursi ng-home-complaint-form
The Statewide Central Register of Child Abuse and Maltreatment 800-342-3720 https://ocfs.ny.gov/main/cps/

Appendix:

Definitions

Abuse: Any of the following acts by an individual service provider:

  1. Physical Abuse: any non-accidental physical contact with a member which causes or has the potential to cause physical harm. Examples include, but are not limited to, hitting, kicking, biting, choking, smothering, shoving, dragging, throwing, punching, shaking, burning, cutting, or the use of corporal punishment.
  2. Psychological Abuse: includes any verbal or nonverbal conduct that is intended to cause a member emotional distress. Examples include, but are not limited to, teasing, taunting, name calling, threats, display of a weapon or other object that could reasonably be perceived by the patient as a means of infliction of pain or injury, insulting or coarse language or gestures directed toward a patient which subjects the individual to humiliation or degradation; violation of an individual's rights or misuse of authority.
  3. Sexual Abuse/Sexual Contact: includes any sexual contact involving a service provider (e.g., HH staff, CMA staff, other provider) and a member. Examples include, but are not limited to, rape, sexual assault, inappropriate touching and fondling, indecent exposure, penetration (or attempted penetration) of vagina, anus or mouth by penis, fingers, or other objects. For purposes of this Part, sexual abuse shall also include sexual activity involving a member and a service provider; or any sexual activity involving a member that is encouraged by a service provider, including but not limited to, sending sexually explicit materials through electronic means (including mobile phones, electronic mail, etc.), voyeurism, or sexual exploitation.
  4. Neglect: any action, inaction or lack of attention that breaches a service provider's duty and that results in or is likely to result in physical injury or serious or protracted impairment of the physical, mental or emotional condition of a member.
  5. Misappropriation of Member Funds: use, appropriation, or misappropriation by a service provider of a member's resources, including but not limited to funds, assets, or property, by deception, intimidation, or similar means, with the intent to deprive the patient of those resources. Examples include the deliberate misplacement, theft, or wrongful, temporary, or permanent use of a member's belongings or money.

Crime Level 1: An arrest of a member for a crime committed against persons (i.e., murder, rape, assault) or crimes against property (i.e., arson, robbery, burglary) AND is perceived to be a significant danger to the community or poses a significant concern to the community.

Death: The death of a member resulting from an apparent homicide, suicide, or unexplained or accidental cause; the death of a member which is unrelated to the natural course of illness or disease.

Exploitation: taking advantage of a member for personal gain through the use of manipulation, intimidation, threats, or coercion.

Missing Person: When a member 18 years of age or older is considered missing AND the disappearance is possibly not voluntary or a Law Enforcement Agency has issued a Missing Person Entry, OR when a child's (under the age of 18) whereabouts are unknown to the child's parent, guardian or legally authorized representative.
Reportable Incident: A reportable incident is an event involving a member, which has, or may have, an adverse effect on the life, health, or welfare of the member.
Restrictive Interventions - According to the CMS Final Rule 42 CFR Part 482 (Federal Register/Vol 71, No. 236, pg. 71427):

  • A restraint is defined as
    1. any manual method, physical or mechanical devise, material, or equipment that immobilizes or reduces the ability of an individual to move his or her arms, legs, body, or head freely; or
    2. a drug or medication when it is used as a restriction to manage the individual's behavior and/or restrict the individual's freedom of movement and is not a standard treatment or dosage for the individual's condition;
    3. a restraint does not include devises, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of an individual for the purpose of conducting routine physical examinations or tests, or to protect the individual from falling out of bed, or to permit the individual to participate in activities without the risk of physical harm (this does not include a physical escort).
  • Seclusion is the involuntary confinement of a patient alone in a room or area from which the individual is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior.

Suicide Attempt: An act committed by a member in an effort to cause his or her own death.

Violation of Protected Health Information: Any violation of a member's rights to confidentiality pursuant to State and Federal laws including, but not limited to, 42 CFR Part 2 or the Health Insurance Portability and Accountability Act (HIPAA), and Article 27F. The CMA has a responsibility to review to determine whether the incident is a breach of security vs. a breach of privacy.