DivisionofResidentialServices

NYSDepartmentofHealth

EffectiveOctober17,2011,theprocessforfacilityreporting incidentstotheDepartmentofHealth(DOH)willchange. FacilitieswillcompletereportsviatheHealthCommerceSystem (HCS),usinganonlinereport versusutilizingtheHotlinetomakea report. ReportswillbeaccessedbytheCentralizedComplaintIntakeUnit (CCIU),triagedandenteredintotheAspenComplaintTracking System(ACTS) CaseResolutionUnit(CRU)staffwillreviewthecasetodetermine appropriateaction. Thirdpartycomplaintswillnotbeeffectedbythisprogram.

FacilitieswillnolongercalltheNursingHomeComplaint Hotline(unlesstheyareunabletoaccessthewebpage) InformationonincidentswillbeobtainedbyCCIUaccessing thewebsite,andthenenteredintoACTS DOHhascreatedadefinedlistofreportableincidents TheDepartmenthasdevelopedanonlinereferencemanual forclarificationofreportableincidents Themanuallistselementsorrelevantcomponents,thatif present,rendertheincidentreportable

Participantswill:

Reviewthebasicprocessofinvestigatingfacilityincidents Gainanunderstandingoftheelectronicfacilityincident reportingsystem Becomeacquaintedwiththeprocessofreportingincidentsvia theHCS Gainawarenessofwhatconstitutesareportableincident.

TheroleoftheDepartmentofHealth: DetermineREGULATORYcompliance. Determineifabuse,mistreatmentorneglecthas occurred Determineifqualityofcarewasachieved Determinethataplantopreventrepeatoccurrences wasdeveloped,communicatedandimplemented

Aninvestigationisthegatheringofevidenceand/ordata relatedtoanoccurrence,orincident.

Thegoalistoarriveatalogicalconclusionbasedon the evidence Facilityinvestigationsmustbeginimmediately,upon discoveryofanincident

Facilitiesarerequiredtoinvestigatethefollowing:

Accidents Injuryofunknownorigin Abuse,mistreatment,neglect Misappropriationofproperty Complaintsrelatedtocare Medicationerrors

Thisisnotanallinclusivelist.

ABUSE Physical/sexualabusebystaff Physical/sexualabusebyresident Physical/sexualabusebyfamilyorvisitor Mistreatment Neglect Dignity/verbalormentalabuse CAREPLANVIOLATIONS Failuretofollowcareplanwithinjury Failuretofollowcareplanwithoutinjury

 ReportableOccurrences
Continued

RESIDENTPROPERTY Misappropriationofproperty QUALITYOFCARE Medicationerrorwithharm/drugdiversion Deathrelatedtosuicide,restraints,equipment

CPRissues Attemptedsuicide Injuryofunknownorigin Burns Accidentsrelatedtochoking Accidentsrelatedtoentrapment Residentfoundinnonresidentarea(basement,stairwell,etc)
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 ReportableOccurrences
Continued

ELOPEMENT Elopementoccurswhenaresidentleavesthebuilding undetectedorfailstoreturnfromapreauthorized leaveofabsence PHYSICALENVIRONMENT Fires/smoke Faultyequipment Physicalplantissues Power,water,electricaloutagesoranyinterruptionof service

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CanbeaccessedonlineontheHCS Containsrelevantinformationforeachreportableincident. Guidesinvestigationbythefacility,andlistsmaterialsthat thefacilityshouldhaveavailabletosurveyors. Themanual listselementsorrelevantcomponents,thatif present,rendertheincidentreportable.

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Themanualalsocontains: Aquestionandanswersectiononbothgeneralmattersandon specificreportingcategories(Thequestionsandanswers provideexamplesanddonotcoverallsituations) Thefacilityrequirementsconcerningtimelyreportingof occurrences,includingFailuretoReport Guidelinesforeachreportableincident Documentsthatshouldbemaintainedwiththefacility investigation

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Thepresenceofelementsdeterminesiftheincidentis reportabletoDOH FOREXAMPLE:physicalabuse Two(2)ofthefollowingelementsareneededforan incidentofabusetobereportedtoDOH: IntentORrecklesslyperformanact Bodilyinjuryand/orseriousbodilyinjury Inappropriatephysicalcontact Repeatedincidentsofresidenttoresidentabuse

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Themanualprovidesguidelinesastorequireddocumentstobeused duringandmaintainedaftertheinvestigation. Example:Physicalabuse

Investigationmaterials: Complete electronic incidentform Haveavailable
Witnessstatement(s) Residentstatement(s) Accusedstatement(s) Photographicevidence(ifavailable) Facilityinvestigation Careplan(s) Residentcognitionevaluation Employeepersonnelandtrainingrecords Plantopreventreoccurrence

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Themanualaddressesreportableincidentsas follows: Topic Regulatoryreference Elements Guidanceoninvestigationmaterialstogather andhaveavailabletothesurveyor Q&ArelatedtoNHscenarios

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ReportsmustbemadetotheDepartmentofHealth immediately uponachievingtheREASONABLECAUSE threshold,revealingthatmisappropriationofproperty, abuse,mistreatmentorneglectoccurred Immediateisdefinedasassoonaspossible,notto exceed24hours Reasonablecauseisdefinedtomeanthatuponareview ofthecircumstances,thereissufficientevidencefora prudentpersontobelievethatphysicalabuse, mistreatmentorneglecthasoccurred ReportsmustbemadetotheDOHwhenthereasonable causethresholdhasbeenachieved,revealingabuse, mistreatmentorneglect FacilityistonotifyDOHwhentheyhavereached reasonablecause,andthenhave5workingdaysto completetheinvestigation.
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Abusehasnotbeenruledout(especiallywithinjuriesof unknownorigin) Facilityinvestigationisinconclusive Staffstatementsareofpoorqualitynotsignedordated,no title,lackpertinentinformation Careplanwasnotappropriatetoresidentsindividualneeds (Forexample,thecareplanwasnotchangedtoreflect residentschangeincondition)

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Concerns Identified During

DOH Investigation

Residenthasahistoryofincidentsbutthecare planfailstoreflectthoseoccurrences Incidentsaredocumentedonacareplan withoutinterventionsoraplantoprevent recurrence Staffisunawareofchangestotheplanofcare. Forexample,theCNAcarddoesnotmatchPOC Careplanisnotalignedwithresidentsneeds. Forexample,careplanlistsanapproachof remindersnottostandbutresidenthas dementiaandcannotremember Unrealisticgoalsandinterventionsarecare planned

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Departmentstaffhasexplicitauthoritytoinspectthefacility, interviewpatientsorresidents,reviewrelevantrecords, observecarebeingprovidedandconductnecessary interviews.LicensedfacilitiesmaynotrequiretheDepartment tomakeanappointmentandmaynotdelayaninspection OurfederalinvestigationactivitiesareguidedbytheState OperationsManual(SOM)andrelatedAppendices TheSOMspecificallyrecognizesthatthedecisiontopermitor denyfacilitypersonnelinvolvementduringthesurveyprocess issolelythatofthesurveyor TheSOMfurthernotesthatrefusalofaccesscanbeabasis forterminationfromtheparticipationintheMedicareand Medicaidprograms

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Theinvestigationleadsyoutodecidewhetherornotto reporttheissuetotheDepartmentthroughtheHealth CommerceSystem,IncidentReportingForm Iftheinvestigationwasthoroughandindicatesthat abuse,neglect,mistreatmentormisappropriation occurred,thenitisareportableincident Iftheinvestigationwasthoroughandoffersnoevidence ofabuse,mistreatment,neglectormisappropriation, youcanbejustifiedinnotreportingittotheHotline, andcannotbecitedforfailuretoreport Inaddition,someincidentsarereportableunderany circumstances,iftherequiredelementsarepresent

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Thefacilitycanbecitedforfailuretocompleteathorough investigation(Ftag225)if: Thesurveyorfindsthattheinvestigationfailedtocometoa reasonableconclusion Thefacility failedtoinvestigatetheincident Thefacility canbecitedforfailuretocompleteathorough investigation(Ftag225) Ifitwasdeterminedthatabuse,mistreatmentorneglect,or misappropriationofpropertyoccurredandnotreportedtoDOH, thentheycanbecitedforfailuretoreport AnycrimemustbereportedtolawenforcementundertheElder JusticeLaw.Section1150BoftheSocialSecurityAct(theAct)as establishedbysection6103(b)(3)ofthePatientProtectionand AffordableCareAct(AffordableCareAct),requiresspecific individualsinlongtermcarefacilitiestoreportareasonable suspicionofcrimescommittedagainstaresident. Thosereports mustbesubmittedtoonelawenforcementagencyofjurisdiction andtheStateSurveyAgency(SA).

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Toreportadditionalinformationtoanexisting case: ContacttheCentralizedComplaintIntakeUnit directlyat18882014563,or Emailtheintakehotlineat NHIntake@health.state.ny.us

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TheDOHhasdevelopedanelectronicincidentreporting system,whichwillallownursinghomestoreporttheir incidentsthroughtheHCS Thenewformwillreplacetheprevioustelephonehotline methodforreportingincidents EffectiveOctober17,2011Facilitieswillberequiredto reportincidentsviathenewIncidentReportingForm availableontheHCS TheDepartmenthasprovidedanIncidentReporting Manualtoclarifythereportingrequirements,andhelp ensurethatfacilitiesarereportingincidentsrequired underStateandFederalstatutesandregulations Themanualprovidesalistofreportableincidentsthat shallbereportedviatheHCS TheDepartmentsrequirementsforreportingincidents areconsistentwithpastreportingrequirements
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ThisPowerPointpresentationhasbeenpreparedtoassist providerstocompletethoroughinvestigationandto preparenursinghomeemployeesabouttheprocessfor investigatingincidents,andwhatconstitutesareportable incident.Thispresentationisavailableonlineforfuture viewing AQuestionandAnswersessionwillbescheduledwiththe ProviderAssociations. TheIncidentReportingForm,PowerPointPresentation,and IncidentReportingManualwillbepostedontheDOH websitewithintheDearAdministratorLettersection.

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Reportingmechanism:https://commerce.health.state.ny.us TheformerIncidentReportingLinephonenumber,1888 2014563,maybeusedincaseofanemergencysuchas yourInternetorcomputersaredown Detailedinstructionmanualisavailableatthewebsite

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Iffacilitystaffhavequestionsonthisprocess, oronreportableincidents,pleasecontact: Theintakehotlineat18882014563, or EmailtheIntakemailboxat Nhintake@health.state.ny.us,or ContactMarkBrownell,AssistantDirectorof theBureauofComplaintsandAnalysisor JoanneBreden,Supervisor,at5184025447

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Todetermineifabuse,mistreatment,neglector misappropriationoccurred Toassurecompliancewithstatutesandregulations Toimprovequalityofcare Toidentifyflawedpractices/policy Toidentifyandcorrectvulnerabilities Toassistwithmanagementofrisk

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Theinvestigationshouldassistthefacilityindeterminingifthe concernwasaresultof: Individual(s)action(staffmemberactedontheirown,outside ofpolicy) Facilitypractice(flawedpracticeorpolicy) Didabuse,mistreatment,neglectormisappropriationof propertyoccur? Theinvestigationshouldruleoutorconfirmabuse, mistreatmentorneglectthroughareviewofsupporting evidence,includinginterviewsandstatementsthatoffervalid information,observationsandrecordreview Theoutcomeisdeterminedbyfacts,basedontheevidence andnotanopinionwhichissubjective

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Interview
Observation
RecordReview

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INTERVIEW:Obtainingstatementfrompartiesdirectlyinvolved andotherspossessingknowledgeofrelevantinformation.This mayincludestaff,residentsandthirdparty OBSERVATION:ofthesurroundingsorscenewheretheincident isallegedtohaveoccurred.Observationofthegeneralcareand conditionoftheareaisveryimportant RECORDREVIEW:reviewofmedicalrecords,careplan,any relateddocuments

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Renderaidtoprotect theresidents,removingthemfrom harm Protectthescene.preserveanyphysicalevidence Collectevidence(askwho,what,when,whereandhow) Determinepresenceofintentbyaggressor Determineyourwitnesses Conductinterviews Documentation(incidentreportingform,medicalrecords, interviewstatements) Determineifabuse,neglectormistreatmenthasoccurred Documentyourconclusions

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CONSIDERTHEFOLLOWING: Withallegationsofabusemistreatmentorneglect:tryto leaveareauntouched,asmuchaspossible Preserveanyevidence/photographs(photosmustbe dated,timedandabletocorrectlyidentifythesubject) Makenoteofresidentconditionandenvironmental conditions Staffobservation Circumstancesjustpriortotheeventordiscovery Evidenceis:Anythingthatwillhelpreconstructthe incident,identifypeopleinvolvedand/oridentifythe responsiblepersons

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Obtainingstatementfrompartiesdirectlyinvolvedand otherspossessinginformation Anonaccusatoryprocessinwhichtheinterviewerasks questionsdesignedtodevelopfactualinformation Documentationmustbesigned,datedandshould includetheindividualstitle

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Who,what,where,when,whyandhow? Maintainalistofthequestionsposedtotheindividualsbeing interviewed Obtainstatementfromtheresident(s),iftheyareableto provideastatementabouttheincident,wheneverpossible

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Takenotesduringtheinterview Provideprivacy,minimizedistractions;listencarefullyandbe patient Whatdoesstaffsay Areyouinterviewingthemordotheyfilloutaform Whatkindofquestionsareyouaskingstaff Questionsshouldbeopenended,designedtoelicit descriptionsofobservations,interventions,orreenactments

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Itfrequentlyisnotenoughtohavestaffwritewhatthey knowDiscussions,includingthefollowingmaybemore informative.

Describeinteractionwithresident Physicaldemonstrationofcaredelivered Didyouseeanyonephysicallyharmresident Describeforceused,stanceofaccusedandanyinjury Didyoucheckthechairalarm Wasitworking DidyouseeSallyusethegaitbelt Whatcantheresidentdoindependently Whatdidthecareplanrequire

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Writtenstatementsareusuallyneededfromtheaccused, andfromwitnesses. Additionalstaffstatementsmaybenecessarytodetermine whatcarewasdelivered.Wasthecareprovidedin accordancewiththeindividualizedplanofcare. Writtenstatementswillneedtobeobtainedinadditionto theinterviews.

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Writtenstatementsshouldbe: Legible Signed,dated,andindicateshiftandjobtitle Thepreferenceistohaveindividualwritetheirown statement,butiftheyareunable,thewritershouldobtain signatureofindividualorhaveitwitnessed

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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 Hasthestaffmemberbeencounseledforcareissuesor failuretofollowthecareplaninthepast Wascareappropriatelydocumented Doesthisindicatethatthecareplanwasfollowed Hasthestaffmemberbeeneducatedortrainedinthearea beinginvestigated,andnotedinthepersonnelrecords

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Allevidenceusedtodeterminetheoutcomeofthe investigationshouldberelevanttothecase Ifthecaseisrelatedtoamedicationisahardcopyofthe properMedicationAdministrationRecordinthecasefile Ifthecaseisrelatedtoacareplanviolation,isthecareplan inthecasefile Allmaterialsrelevanttotheoutcomeshouldbeincludedin thefile

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Whatisathoroughinvestigation

Onethatcomestoareasonableconclusionastohowand/or whysomethingoccurred Theinvestigationshouldruleoutorconfirmabuse, mistreatmentorneglectbyreviewofsupportingevidence, includinginterviewsandstatementsthatoffervalid information,observationsandrecordreview Theoutcomeisdeterminedbyfact,basedontheevidence andnotonopinion

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Uponreviewingalloftheevidence,aconclusionisdetermined.

Didabuse,mistreatmentorneglectoccur Isthereapolicyorpracticeissuethatcausedrisk Isthisanisolatedincidentorasystemicproblem Doestheevidencesupporttheoutcome

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Immediately,takecorrectiveactionincludingeducation Identifytrends ImplementandcommunicateQIinterventionsforlong termpreventionofrecurrenceofthematter Periodicallyreviewandreviseinterventions

Reporttoappropriateagencyasnecessary:

Ifabuse,mistreatment,neglectormisappropriation, contactlawenforcement Ifaprofessionalissue,contactStateEducationorDOH OfficeofProfessionalMisconduct(OPMC) Ifcontrolledsubstanceissue,contacttheDOHBureauof NarcoticEnforcement(BNE)

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