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DSL Memo Series 2003-02

 

January 8, 2003

STATE OF WISCONSIN
Department of Health and Family Services
Division of Supportive Living

To:
Area Administrators/Assistant Area Administrators
Bureau Directors
County Departments of Community Programs Directors
County Departments of Developmental Disabilities Services Directors
County Departments of Human Services Directors
County Departments of Social Services Directors
Licensing Chiefs/Section Chiefs
Tribal Chairpersons/Human Services Facilitators

From: 
Sinikka McCabe, Administrator

Re: RESPONDING TO AND REPORTING CRITICAL INCIDENTS IN CIP 1A/B, CSLA AND BRAIN INJURY WAIVERS

Document Summary

This memo defines the content and format for critical incident reporting in BDDS-administered MA Waivers. It communicates the Division's policy requiring County Agencies to report critical incidents, defines these incidents and describes the way counties make these reports. This policy will come into effect 30 days after the date of this memo but will apply to all 2003 incidents.

The assurance of health, safety and welfare of program participants is a condition of approval of all Medicaid (MA) Waivers by the federal Centers for Medicare and Medicaid Services (CMS). County agencies are required to address this pursuant to conditions in the state/county contract and the Medicaid Waivers Manual. One of the ways both counties and the Department assure health, safety and welfare in MA Waivers administered by the Bureau of Developmental Disabilities Services (BDDS) is by reporting, monitoring and resolving critical incidents. Since 1997, Chapter 9, section 9.06 of the MA Waivers Manual has included an explicit requirement for counties to report critical incidents involving individuals served on waivers administered by BDDS to the regionally based Community Integration Specialist (CIS). A standard definition of these events or prescribed reporting format was not included in the Manual. This has made it difficult to document the frequency and nature of all critical incidents. CMS in their recent review of the Brain Injury Waiver program recommended standardization of the reporting process in the format supplied in this memo. This DSL memo contains a definition of critical incidents and establishes a prescribed format for counties to use in reporting these incidents.

The definitions used come from either statutes or administrative rules. The reporting format in this memo has been in use for a number of years with state staff completing the critical incident report based on verbal and written communications with county staff. The original internal BDDS system was developed with informal advice from a number of counties that already had incident management systems in place. In fact, Winnebago County's system was used as the model for the system described below.

CRITICAL INCIDENTS DEFINED

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 a waiver participant. The critical incidents covered by this memo that must be reported include:

  • Any abuse or neglect of the participant inflicted by others;

  • Any misappropriation of the personís funds or property;

  • A violation of the persons rights under S. 51.61 WI Stats. And Chapter HFS 94;

  • All unexpected, untimely and urgent emergency hospital admissions including any that are or may be the result of substandard care; this excludes urgent care clinic visits for acute physical health issues;

  • Errors in medical or medication management that result or could result in significant adverse medical reactions or behavioral responses indicating a threat to the personís health;

  • The initiation of an investigation by law enforcement authorities of an event or allegation that involves a waiver participant either as a perpetrator or victim that may lead to criminal charges;

  • Any death of a waiver participant including those by natural causes. (This does not replace any other death reporting requirements);

  • All suspected or confirmed suicide attempts by a waiver participant;

  • A fire in the home or facility in which the participant lives or where the participant was receiving services if the fire required the response of a fire department and created a significant risk to the participantís health or safety;

  • Significant damage to property including but not limited to the property of the waiver participant, service providers, to the participantís residence, place of employment or other place the participant frequents if such property damage poses or posed a threat to the personís health, safety or welfare. Includes damages that are the result of acts of nature such as storms.

  • Unsafe or unsanitary environmental conditions in a personís home or place where the individual receives services;

  • Use of isolation, seclusion, or restraint (physical or chemical) by a service provider in violation of S. 51.61 WI Stats. , HFS 94.10 without county and the Departmentís prior approval;

  • Unanticipated absence of the participant including any unauthorized leaving by the participant such as wandering or intentionally leaving which suggest that the participant is at risk of harm.

*County staff should take special note that reporting critical incidents on this system does not eliminate any other reporting requirements. All other required reporting procedures such as child abuse or caregiver reporting or notifying BQA of possible code violations and the timelines of these other required reporting systems remain in force and are not replaced or superseded by this process.

APPLICATION

The subjects to whom this memo applies are Medicaid Waiver participants with a developmental disability or acquired brain injury who participate in one of the MA Waivers administered by the Bureau of Developmental Disabilities Services (BDDS). Responsibility for responding to such incidents is with the county agency operating the Medicaid Waiver. Counties are encouraged to make the responsibility for reporting and the procedures recommended in the attached instructions a condition of their contracts or agreements with all service providers.

THE CRITICAL INCIDENT REPORTING AND RESPONSE PROCESS

Counties are expected to have an effective response process in which county staff or their agents address and resolve the situations and implement systems to decrease the likelihood of a recurrence. The report documents the occurrence of the incident and describes the countyís response by their staff or contract agencies. Reports must contain accurate and timely information. BDDS will use the Critical Incident Reports to identify statewide or regional trends, which will then allow the development of interventions to decrease the likelihood of reoccurrence.

The critical incident response process begins with local staff learning of the situation. They determine what has occurred and determine the response needed. Critical incidents that have been confirmed to have occurred or exist as well as alleged critical incidents that have not yet been determined to be founded or unfounded should be reported. If the reported critical incident is determined to be unfounded the report will be withdrawn. The response by county staff is intended to remove the waiver participant from danger and resolve the situation to remove the risk. The event and the response are to be reported to the assigned CIS for the county within five days of learning of the event. Often these reports initially are done by phone and might result in a collaborative effort by state and local staff. Such efforts often attempt to constructively resolve problem situations. State CIS serve as consultants, often serve a liaison function with other units in the Department such as the Bureau of Quality Assurance (BQA) or may get involved by assisting with increased on-site monitoring of some situations. Critical incident follow up may be completed in as short of time as a day or may involve a number of corrective actions that may occur over a longer period of time. The incident investigation may also lead to follow up monitoring by both county and state staff and plans of correction for the county or the provider involved.

THE CRITICAL INCIDENT REPORT (CIR)

Reportable incidents must be reported using the prescribed format provided in this memo. The attached Critical Incident Report must be sent to the Bureau of Developmental Disabilities Servicesí Central Office within five working days of the county learning of the situation. For active and urgent situations, County staff should also report the incident by phone to their assigned CIS. (Phone numbers are in the Medicaid Waivers Manual, Appendix L.) County staff may also make other arrangements with the CIS concerning the due date for submission of the form. Additional reporting concerning the progress and disposition of the event that occurs after initial reports shall be done in a timely way. All CIRs must include information necessary for BDDS to close the incident record.

Reports shall be mailed or faxed to:
Critical Incident Report Contact
Waiver Program Assistant
Bureau of Development Disabilities Services
P. O. Box 7851
Madison, WI 53708
FAX (608) 261-6752

County staff are strongly encouraged to report serious and active incidents to their CIS by phone immediately on learning of the situation. Department staff must often respond to inquiries from police, legislators, advocacy organizations, the press and others. Accurate and up to date information helps us assure these groups that events are being handled appropriately. In serious and active situations, make sure you talk to someone from BDDS in person and not just leave a message on someone's voice mail. The first point of contact is the county assigned CIS. If the CIS is not available, please call the central phone number at BDDS 608-266-0805 and ask to speak with a manager.

The paper form is attached to this memo. In the future, the form will be available in a format that counties can use with word processing programs. It is also our intent to expand the use of data collected on this form to further analyze the nature and extent of CIRs to identify patterns. Specifically, we hope to identify trends and clusters of critical incidents including providers with persistent incidents to make adjustments and improvements as needed. The results of such efforts will be shared with counties to assist future state and local quality improvement efforts. It is our hope and belief that this process will improve the quality of care in our Medicaid Waiver programs.

IMPLEMENTATION

Counties are required to implement the requirements of this memo as quickly as possible. Counties have a 90-day implementation period from the date of this memo to work out the procedures and inform affected providers and staff. All critical incidents that occur on or after January 1, 2003 shall be reported. This will permit the department to have and analyze a full years worth of data. Since critical incident reporting was previously required by Chapter 9 of the Medicaid Waivers Manual, and this new requirement including the form and instructions will be added to Chapter 9 of the revised Manual.

We ask and thank you for your cooperation in this effort.

REGIONAL OFFICE CONTACT:
Community Integration Specialist

CENTRAL OFFICE CONTACT:
Camille Rodriguez-Williams
DLTC/BLTS
(608) 266-9366

Attachments: 
Instructions for Completing Critical Incident Reports 

DDE-2558 (PDF)

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