11 12 presentation

8/2/2019 11 12 Presentation

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DDDDiiiivvvviiiissssiiiioooonnnnooooffffRRRReeeessssiiiiddddeeeennnnttttiiiiaaaallllSSSSeeeerrrrvvvviiiicccceeeessssNNNNYYYYSSSSDDDDeeeeppppaaaarrrrttttmmmmeeeennnnttttooooffffHHHHeeeeaaaalllltttthhhh

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EffectiveOctober17,2011,theprocessforfacilityreportingincidentstotheDepartmentofHealth(DOH)willchange.FacilitieswillcompletereportsviatheHealthCommerceSystem(HCS),usinganonlinereportversusutilizingtheHotlinetomakeareport.ReportswillbeaccessedbytheCentralizedComplaintIntakeUnit(CCIU),triagedandenteredintotheAspenComplaintTrackingSystem(ACTS)CaseResolutionUnit(CRU)staffwillreviewthecasetodetermineappropriateaction.Thirdpartycomplaintswillnotbeeffectedbythisprogram.

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FacilitieswillnolongercalltheNursingHomeComplaintHotline(unlesstheyareunabletoaccessthewebpage)

InformationonincidentswillbeobtainedbyCCIUaccessingthewebsite,andthenenteredintoACTS

DOHhascreatedadefinedlistofreportableincidents TheDepartmenthasdevelopedanonlinereferencemanual

forclarificationofreportableincidents Themanuallistselementsor relevantcomponents,thatif

present,rendertheincidentreportable

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Participantswill: Reviewthebasicprocessofinvestigatingfacilityincidents Gainanunderstandingoftheelectronicfacilityincident

reportingsystem Becomeacquaintedwiththeprocessofreportingincidentsvia

theHCS Gainawarenessofwhatconstitutesareportableincident.

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TheroleoftheDepartmentofHealth: DetermineREGULATORYcompliance.Determineifabuse,mistreatmentorneglecthas

occurredDetermineifqualityofcarewasachievedDeterminethataplantopreventrepeatoccurrences

wasdeveloped,communicatedandimplemented

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An

investigation

is

the

gathering

of

evidence

and/or

data

relatedtoanoccurrence,orincident. Thegoalistoarriveatalogicalconclusionbasedon the

evidence Facilityinvestigationsmustbeginimmediately,upon

discoveryofanincident

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Facilitiesarerequiredtoinvestigatethefollowing: Accidents Injuryofunknownorigin Abuse,mistreatment,neglect Misappropriationofproperty Complaintsrelatedtocare MedicationerrorsThisisnotanallinclusivelist.

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AAAABBBBUUUUSSSSEEEE Physical/sexualabusebystaff Physical/sexualabusebyresident Physical/sexualabusebyfamilyorvisitor Mistreatment Neglect Dignity/verbalormentalabuseCCCCAAAARRRREEEEPPPPLLLLAAAANNNNVVVVIIIIOOOOLLLLAAAATTTTIIIIOOOONNNNSSSS Failuretofollowcareplanwithinjury Failuretofollowcareplanwithoutinjury

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RRRReeeeppppoooorrrrttttaaaabbbblllleeeeOOOOccccccccuuuurrrrrrrreeeennnncccceeeessssCCCCoooonnnnttttiiiinnnnuuuueeeedddd

RRRRE

EEES

SSSI

IIIDDDDE

EEEN

NNNT

TTTP

PPPR

RRRO

OOOP

PPPE

EEER

RRRT

TTTY

YYY

MisappropriationofpropertyQQQQUUUUAAAALLLLIIIITTTTYYYYOOOOFFFFCCCCAAAARRRREEEE Medicationerrorwithharm/drugdiversion Deathrelatedtosuicide,restraints,equipment CPRissues Attemptedsuicide Injuryofunknownorigin

Burns

Accidentsrelatedtochoking Accidentsrelatedtoentrapment Residentfoundinnon-residentarea(basement,stairwell,etc)

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RRRReeeeppppoooorrrrttttaaaabbbblllleeeeOOOOccccccccuuuurrrrrrrreeeennnncccceeeessssCCCCoooonnnnttttiiiinnnnuuuueeeeddddEEEELLLLOOOOPPPPEEEEMMMMEEEENNNNTTTT Elopementoccurswhenaresidentleavesthebuilding

undetectedorfailstoreturnfromapreauthorizedleaveofabsence

PPPPHHHHYYYYSSSSIIIICCCCAAAALLLLEEEENNNNVVVVIIIIRRRROOOONNNNMMMMEEEENNNNTTTT Fires/smoke Faultyequipment

Physicalplant

issues

Power,water,electricaloutagesoranyinterruptionof

service

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CanbeaccessedonlineontheHCS Containsrelevantinformationforeachreportableincident. Guidesinvestigationbythefacility,andlistsmaterialsthat

thefacilityshouldhaveavailabletosurveyors. Themanual listselementsor relevantcomponents,thatif

present,rendertheincidentreportable.

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TTTThhhheeeemmmmaaaannnnuuuuaaaallll aaaallllssssooooccccoooonnnnttttaaaaiiiinnnnssss::::Aquestionandanswersectiononbothgeneralmattersandonspecificreportingcategories((((TTTThhhheeeeqqqquuuueeeessssttttiiiioooonnnnssssaaaannnnddddaaaannnnsssswwwweeeerrrrsssspppprrrroooovvvviiiiddddeeeeeeeexxxxaaaammmmpppplllleeeessssaaaannnnddddddddoooonnnnoooottttccccoooovvvveeeerrrraaaallllllllssssiiiittttuuuuaaaattttiiiioooonnnnssss))))Thefacilityrequirementsconcerningtimelyreportingofoccurrences,includingFailuretoReportGuidelinesforeachreportableincidentDocumentsthatshouldbemaintainedwiththefacilityinvestigation

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Thepresenceofelementsdeterminesiftheincidentisreportable

to

DOH

FOREXAMPLE: physicalabuse

Two(2)ofthefollowingelementsareneededforanincidentofabusetobereportedtoDOH: IntentORrecklesslyperformanact Bodilyinjuryand/orseriousbodilyinjury Inappropriatephysicalcontact Repeatedincidentsofresidenttoresidentabuse

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Themanualprovidesguidelinesastorequireddocumentstobeusedduringandmaintainedaftertheinvestigation.Example: PhysicalabuseInvestigationmaterials: Completeelectronicincidentform Haveavailable

Witnessstatement(s) Residentstatement(s) Accusedstatement(s) Photographicevidence(ifavailable) Facilityinvestigation Careplan(s)

Residentcognition

evaluation

Employeepersonnelandtrainingrecords Plantopreventreoccurrence

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Themanualaddressesreportableincidentsasfollows: Topic Regulatoryreference

Elements

Guidanceoninvestigationmaterialstogatherandhaveavailabletothesurveyor

Q&ArelatedtoNHscenarios

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ReportsmustbemadetotheDepartmentofHealthiiiimmmmmmmmeeeeddddiiiiaaaatttteeeellllyyyyuponachievingtheRRRREEEEAAAASSSSOOOONNNNAAAABBBBLLLLEEEECCCCAAAAUUUUSSSSEEEEthreshold,revealingthat misappropriationofproperty,abuse,mistreatmentorneglectoccurred

Immediateisdefinedasassoonaspossible,nottoexceed24hours

Reasonablecauseisdefinedtomeanthatuponareviewofthecircumstances,thereissufficientevidenceforaprudentpersontobelievethatphysicalabuse,mistreatmentorneglecthasoccurred

ReportsmustbemadetotheDOHwhenthereasonablecausethresholdhasbeenachieved,revealingabuse,mistreatmentorneglect

FFFFaaaacccciiiilllliiiittttyyyyiiiissssttttoooonnnnoooottttiiiiffffyyyyDDDDOOOOHHHHwwwwhhhheeeennnntttthhhheeeeyyyyhhhhaaaavvvveeeerrrreeeeaaaacccchhhheeeeddddrrrreeeeaaaassssoooonnnnaaaabbbblllleeeeccccaaaauuuusssseeee,,,,aaaannnnddddtttthhhheeeennnnhhhhaaaavvvveeee5555wwwwoooorrrrkkkkiiiinnnnggggddddaaaayyyyssssttttoooocomplete the investigation.complete the investigation.complete the investigation.completetheinvestigation.

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Abusehasnotbeenruledout(especiallywithinjuriesofunknownorigin)

Facilityinvestigationisinconclusive Staffstatementsareofpoorqualitynotsignedordated,no

title,lackpertinentinformation Careplanwasnotappropriatetoresidentsindividualneeds

(Forexample,thecareplanwasnotchangedtoreflectresidentschangeincondition)

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Concerns Identified DuringDOH Investigation

Residenthasahistoryofincidentsbutthecareplanfailstoreflectthoseoccurrences

Incidentsaredocumentedonacareplanwithoutinterventionsoraplantopreventrecurrence

Staffisunawareof changestotheplanofcare.Forexample,theCNAcarddoesnotmatchPOC

Careplanisnotalignedwithresidentsneeds.Forexample,careplanlistsanapproachofremindersnottostandbutresidenthasdementiaandcannotremember

Unrealisticgoalsandinterventionsarecareplanned

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Departmentstaffhasexplicitauthoritytoinspectthefacility,interviewpatientsorresidents,reviewrelevantrecords,observecarebeingprovidedandconductnecessaryinterviews.LLLLiiiicccceeeennnnsssseeeeddddffffaaaacccciiiilllliiiittttiiiieeeessssmmmmaaaayyyynnnnoooottttrrrreeeeqqqquuuuiiiirrrreeeetttthhhheeeeDDDDeeeeppppaaaarrrrttttmmmmeeeennnnttttttttoooommmmaaaakkkkeeeeaaaannnnaaaappppppppooooiiiinnnnttttmmmmeeeennnnttttaaaannnnddddmmmmaaaayyyynnnnoooottttddddeeeellllaaaayyyyaaaannnniiiinnnnssssppppeeeeccccttttiiiioooonnnn

OurfederalinvestigationactivitiesareguidedbytheStateOperationsManual(SOM)andrelatedAppendices

TheSOMspecificallyrecognizesthattttthhhheeeeddddeeeecccciiiissssiiiioooonnnnttttooooppppeeeerrrrmmmmiiiittttoooorrrrddddeeeennnnyyyyffffaaaacccciiiilllliiiittttyyyyppppeeeerrrrssssoooonnnnnnnneeeelllliiiinnnnvvvvoooollllvvvveeeemmmmeeeennnnttttdddduuuurrrriiiinnnnggggtttthhhheeeessssuuuurrrrvvvveeeeyyyypppprrrroooocccceeeessssssssiiiissssssssoooolllleeeellllyyyytttthhhhaaaattttoooofffftttthhhheeeessssuuuurrrrvvvveeeeyyyyoooorrrr

TheSOMfurthernotesthatrefusalofaccesscanbeabasisforterminationfromtheparticipationintheMedicareandMedicaidprograms

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TheinvestigationlllleeeeaaaaddddssssyyyyoooouuuuttttooooddddeeeecccciiiiddddeeeewhetherornottoreporttheissuetotheDepartmentthroughtheHealthCommerce

System,

Incident

Reporting

Form

Iftheinvestigationwasthoroughandindicatesthat

aaaabbbbuuuusssseeee,,,,nnnneeeegggglllleeeecccctttt,,,,mmmmiiiissssttttrrrreeeeaaaattttmmmmeeeennnnttttoooorrrrmmmmiiiissssaaaapppppppprrrroooopppprrrriiiiaaaattttiiiioooonnnnooooccccccccuuuurrrrrrrreeeedddd,,,,tttthhhheeeennnniiiittttiiiissssaaaarrrreeeeppppoooorrrrttttaaaabbbblllleeeeiiiinnnncccciiiiddddeeeennnntttt

Iftheinvestigationwasthoroughandooooffffffffeeeerrrrssssnnnnooooeeeevvvviiiiddddeeeennnncccceeeeooooffffaaaabbbbuuuusssseeee,,,,mmmmiiiissssttttrrrreeeeaaaattttmmmmeeeennnntttt,,,,nnnneeeegggglllleeeeccccttttoooorrrrmmmmiiiissssaaaapppppppprrrroooopppprrrriiiiaaaattttiiiioooonnnn,,,,yyyyoooouuuuccccaaaannnnbbbbeeeejjjjuuuussssttttiiiiffffiiiieeeeddddiiiinnnnnnnnoooottttrrrreeeeppppoooorrrrttttiiiinnnnggggiiiittttttttooootttthhhheeeeHHHHoooottttlllliiiinnnneeee,,,,aaaannnnddddccccaaaannnnnnnnoooottttbbbbeeeecccciiiitttteeeeddddffffoooorrrrffffaaaaiiiilllluuuurrrreeeettttoooorrrreeeeppppoooorrrrtttt

Inaddition,someincidentsarereportableunderanycircumstances,iftherequiredelementsarepresent

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Thefacilitycanbecitedforfailuretocompleteathoroughinvestigation(Ftag225)if: Thesurveyorfindsthattheinvestigationfailedtocometoa

reasonableconclusion Thefacility failedtoinvestigatetheincident Thefacilitycanbecitedforfailuretocompleteathorough

investigation(Ftag225) Ifitwasdeterminedthatabuse,mistreatmentorneglect,or

misappropriationof

property

occurred

and

not

reported

to

DOH,

thentheycanbecitedforfailuretoreport

AnycrimemustbereportedtolawenforcementundertheElderJusticeLaw.Section1150BoftheSocialSecurityAct(theAct)asestablishedbysection6103(b)(3)ofthePatientProtectionandAffordableCareAct(AffordableCareAct),requiresspecificindividuals

in

long

term

care

facilities

to

report

a

reasonable

suspicionofcrimescommittedagainstaresident. ThosereportsmustbesubmittedtoonelawenforcementagencyofjurisdictionandtheStateSurveyAgency(SA).

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Toreportadditionalinformationtoanexistingcase: ContacttheCentralizedComplaintIntakeUnit

directlyat1888-201-4563,or Emailtheintakehotlineat

[email protected]

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mailto:[email protected]:[email protected]


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TheDOHhasdevelopedanelectronicincidentreportingsystem,whichwillallownursinghomestoreporttheirincidentsthroughtheHCS

Thenewformwillreplacetheprevioustelephonehotlinemethodforreportingincidents

EffectiveOctober17,2011FacilitieswillberequiredtoreportincidentsviathenewIncidentReportingFormavailableontheHCS

TheDepartmenthasprovidedanIncidentReportingManualtoclarifythereportingrequirements,andhelpensurethatfacilitiesarereportingincidentsrequiredunderStateandFederalstatutesandregulations

Themanual

provides

a

list

of

reportable

incidents

that

shallbereportedviatheHCS

TheDepartmentsrequirementsforreportingincidentsareconsistentwithpastreportingrequirements

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ThisPowerPointpresentationhasbeenpreparedtoassistproviderstocompletethoroughinvestigationandtopreparenursinghomeemployeesabouttheprocessforinvestigatingincidents,andwhatconstitutesareportableincident. ThispresentationisavailableonlineforfutureviewingAQuestionandAnswersessionwillbescheduledwiththeProviderAssociations.TheIncidentReportingForm,PowerPointPresentation,andIncidentReportingManualwillbepostedontheDOHwebsitewithintheDearAdministratorLettersection.

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Reportingmechanism: https://commerce.health.state.ny.us TheformerIncidentReportingLinephonenumber,1-888-

201-4563,maybeusedincaseofanemergencysuchasyourInternetorcomputersaredown

Detailedinstructionmanualisavailableatthewebsite

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http:///reader/full/https://commerce.health.state.ny.ushttp:///reader/full/https://commerce.health.state.ny.us


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Iffacilitystaffhavequestionsonthisprocess,oronreportableincidents,pleasecontact:

Theintakehotlineat1-888-201-4563,or EmailtheIntakemailboxat

[email protected],or ContactMarkBrownell,AssistantDirectorof

theBureauofComplaintsandAnalysisorJoanneBreden,Supervisor, at518-402-5447

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mailto:[email protected]:[email protected]


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Todetermineifabuse,mistreatment,neglectormisappropriation occurred

Toassurecompliancewithstatutesandregulations Toimprovequalityofcare Toidentifyflawedpractices/policy Toidentifyandcorrectvulnerabilities Toassistwithmanagementofrisk

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Theinvestigationshouldassistthefacilityindeterminingiftheconcernwasaresultof:

Individual(s)action

(staff

member

acted

on

their

own,

outside

ofpolicy)

Facilitypractice(flawedpracticeorpolicy)Didabuse,mistreatment,neglectormisappropriationofpropertyoccur? Theinvestigationshouldruleoutorconfirmabuse,

mistreatmentorneglectthroughareviewofsupportingevidence,includinginterviewsandstatementsthatoffervalidinformation,observationsandrecordreview

Theoutcomeisdeterminedbyfacts,basedontheevidenceandnotanopinionwhichissubjective

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IIIInnnntttteeeerrrrvvvviiiieeeewwww

OOOObbbbsssseeeerrrrvvvvaaaattttiiiioooonnnnRRRReeeeccccoooorrrrddddRRRReeeevvvviiiieeeewwww

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INTERVIEW:Obtainingstatementfrompartiesdirectlyinvolvedandotherspossessingknowledgeofrelevantinformation.Thismay

include

staff,

residents

and

third

party

OBSERVATION:ofthesurroundingsorscenewheretheincidentisallegedtohaveoccurred.ObservationofthegeneralcareandconditionoftheareaisveryimportantRECORDREVIEW: reviewofmedicalrecords,careplan,anyrelateddocuments

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Renderaidtopppprrrrooootttteeeecccctttttheresidents,removingthemfromharm

Protectthescene.preserveanyphysicalevidence Collectevidence(askwho,what,when,whereandhow) Determinepresenceofintentbyaggressor Determineyourwitnesses Conductinterviews Documentation(incidentreporting form,medicalrecords,

interviewstatements) Determineifabuse,neglectormistreatmenthasoccurred Documentyourconclusions

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CONSIDERTHEFOLLOWING: Withallegationsofabusemistreatmentorneglect:tryto

leavearea

untouched,

as

much

as

possible

Preserveanyevidence/photographs(photosmustbe

dated,timedandabletocorrectlyidentifythesubject) Makenoteofresidentconditionandenvironmental

conditions Staffobservation Circumstancesjustpriortotheeventordiscovery Evidenceis:Anythingthatwillhelpreconstructthe

incident,identifypeopleinvolvedand/oridentifytheresponsiblepersons

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Obtainingstatementfrompartiesdirectlyinvolvedandotherspossessinginformation

Anon-accusatoryprocessinwhichtheinterviewerasksquestionsdesignedtodevelopfactualinformation

Documentationmustbesigned,datedandshouldincludetheindividualstitle

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Who,what,where,when,whyandhow?Maintainalistofthequestionsposedtothe individualsbeinginterviewedObtainstatementfromtheresident(s),iftheyareabletoprovideastatementabouttheincident,wheneverpossible

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Takenotesduringtheinterview Provideprivacy,minimizedistractions;listencarefullyandbepatient Whatdoesstaffsay Areyouinterviewingthemordotheyfilloutaform Whatkindofquestionsareyouaskingstaff Questionsshouldbeopenended,designedtoelicit

descriptionsofobservations, interventions,orre-enactments

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ItfrequentlyisnotenoughtohavestaffwritewhattheyknowDiscussions,includingthefollowingmaybemoreinformative. Describeinteractionwithresident Physicaldemonstrationofcaredelivered Didyouseeanyonephysicallyharmresident Describeforceused,stanceofaccusedandanyinjury Didyoucheckthechairalarm Wasitworking DidyouseeSallyusethegaitbelt Whatcantheresidentdoindependently Whatdidthecareplanrequire

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Writtenstatementsareusuallyneededfromtheaccused,andfromwitnesses.Additionalstaffstatementsmaybenecessarytodeterminewhatcarewasdelivered. Wasthecareprovidedinaccordancewiththeindividualizedplanofcare.Writtenstatementswillneedtobeobtainedinadditiontotheinterviews.

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Writtenstatementsshouldbe: Legible Signed,dated,andindicateshiftandjobtitle Thepreferenceistohaveindividualwritetheirown

statement,butiftheyareunable,thewritershouldobtainsignatureofindividualorhaveitwitnessed

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Whatdidyousee Whatdidotherssee Whatdoestheenvironmenttellyou Isthereevidencethatthecareplanwasfollowed Whatdoyouseewhenyoulookatorspeaktootherresidents Whatdoyouhearwhenwalkingthroughtheunit Doyouseeevidenceofpotentialabuseorconcern

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Whatwasrequiredbycareplan Wasitanappropriateindividualizedplanofcare Whataretheresidentsriskfactors AretheriskfactorsidentifiedinthePlanofCare Wasthecareplanfollowed Whatwasdocumentedupondiscoveryofevent Whatdonursesreportsindicate WereMDordersfollowed WastheCNArecordcompletedaccurately Werefacilitypoliciesandproceduresfollowed

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Doesthecareplanneedtobeupdatedtopreventrecurrence Isanythinggoingonmedicallythatsbeenmissed (UTI? URI?

Labs?)

Whatistheresidentshistory Whatistheresidentsbehavior Doesthecareplanreflectactualcareneeded DoesCNAcareplanmatchthecomprehensivecareplan DoestheCNAcareplangivespecificinformationtothestaff

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Isthereastaffmemberinvolved Whatisthestaffmembersperformancehistory Hasthestaffmember beencounseledforcareissuesorfailuretofollowthecareplaninthepast Wascareappropriatelydocumented Doesthisindicatethatthecareplanwasfollowed Hasthestaffmemberbeeneducatedortrainedintheareabeinginvestigated,andnotedinthepersonnelrecords

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Allevidenceusedtodeterminetheoutcomeoftheinvestigation

should

be

relevant

to

the

case

Ifthecaseisrelatedtoamedicationisahardcopyofthe

properMedicationAdministrationRecordinthecasefile Ifthecaseisrelatedtoacareplanviolation,isthecareplan

inthecasefile Allmaterialsrelevanttotheoutcomeshouldbeincludedin

thefile

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Whatisathoroughinvestigation Onethatcomestoareasonableconclusionastohowand/orwhysomethingoccurred Theinvestigationshouldruleoutorconfirmabuse,

mistreatmentorneglectbyreviewofsupportingevidence,includinginterviewsandstatementsthatoffervalidinformation,observationsandrecordreview

Theoutcomeisdeterminedbyfact,basedontheevidenceandnotonopinion

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Uponreviewingalloftheevidence,aconclusionisdetermined. Didabuse,mistreatmentorneglectoccur Isthereapolicyorpracticeissuethatcausedrisk Isthisanisolatedincidentorasystemicproblem Doestheevidencesupporttheoutcome

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Immediately,take correctiveactionincludingeducation Identifytrends ImplementandcommunicateQIinterventionsforlong

termpreventionofrecurrenceofthematter PeriodicallyreviewandreviseinterventionsReportto appropriateagencyasnecessary: Ifabuse,mistreatment,neglectormisappropriation,

contactlawenforcement Ifaprofessionalissue,contactStateEducationorDOH

OfficeofProfessionalMisconduct(OPMC) Ifcontrolledsubstanceissue,contacttheDOHBureauof

NarcoticEnforcement(BNE)47