IRIS- Incident Response
Improvement System Training
October 9, 2013
Presented by: Ashley Armstrong
Contact Information for Questions:
providermonitoring@eastpointe.net
What is IRIS?
The DHHS IRIS is a web based
incident reporting system for reporting
and documenting Level II and III
incidents that involve consumers who
receive MH/DD/SA funds
Who must submit Incident Reports?
Providers of publicly funded services licensed
under NC General Statutes 122C, except
hospitals, (Category A providers) and
providers of publicly funded non-licensed
periodic or community-based MH/DD/SA
services (Category B providers).
LME/ MCO Role In IRIS
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Verify incidents and review the 72 hour listing with providers daily.
Review for any Safety Concerns and request Safety Plan, if needed
Review for data completeness and request any additional information needed
Review to assure all appropriate guardian/ agencies have been notified- refer if needed
Discuss additional information/ reports needed such as police reports, Medical examiner reports,
hospital discharge, etc.
Send incident number to providers
Assess (or refer to applicable team within LME/MCO) if Provider Monitoring is needed
Review Quarterly Provider Report for any concerns or need for Provider Monitoring
Contact DMH/DD/SAS within 24 hours (business days) on Level IIIs – unless any media
involvement
If incident is reported or likely to be reported in media, contact DMH/DD/SAS as soon as possibleon the same day.
Review provider handling to ensure safety of consumers, certified copy of record and provider’s
review committee convened.
Monitor and provide technical assistance as warranted to ensure that problems are
corrected.
Analyze and respond to patterns of incidents as part of review of QI monitoring processes
Review of monthly Unknown Death Report
DMH/DD/ SAS Role in IRIS
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Weekly contact with LME/MCO for follow-up on reports
Review of monthly Unknown Death Report
Review to assure all appropriate guardian/ agencies have been
notified- refer if needed
Inform all appropriate DMH/DD/SAS staff
Discuss/ provide technical assistance to LMEs/ MCOs with plans or
strategies for complex cases
Analyze and respond to statewide patterns of incidents as part of
review of QI monitoring and LME/MCO oversight of response
processes
What is an Incident?
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An incident is “any happening which is not
consistent with the routine care of a
consumer and that is likely to lead to adverse
effects upon a consumer” as defined in 10A
NCAC 27G .0103(b)(32).
There are 3 levels of response to incidents,
based on the potential or active severity of
the event. Levels are Level I, Level II, &
Level III.
Confidentiality
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All incident reports are confidential quality
assurance documents.
Do not file incident reports in the individual’s
service record.
Use this form according to confidentiality
requirements in NC General Statutes and
Administrative Code and in the Code of
Federal Regulations.
Reporting Guidelines
Documentation of All Incidents –
 All incidents should be documented and
analyzed as part of agencies QA/QI process.
 Complete all required sections for level II & III
incidents
 Give as much information that is known.
Reporting Guidelines (continued)
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Level I incidents are documented on
agency’s internal forms. Level I incidents are
not submitted in IRIS.
Level II & III incidents must be submitted in
IRIS.
NEVER file incidents reports in individual’s
service record.
Under Provider Care
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“a consumer under the care of a provider” refers to a
consumer who has received any service in the 90
days prior to the incident.
Individuals who receive Residential or ACTT
services are considered under the provider’s care 24
hours a day.
Individuals receiving day services or periodic
services are considered under the provider’s care
while a staff person is providing services or if the
consumer received any services from the provider in
the 90 days prior to the incident.
Under Provider Care (continued)
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Providers of crisis, day, and periodic services
should report all deaths and errors in selfadministration of medication upon learning of
the incident, even if it did not happen while
under the provider’s care.
For additional Information, please refer to
Implementation Update # 55.
What staff submits?
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The staff person most knowledgeable about
the incident should complete the information
on the report as soon as possible after
learning of the incident.
The staff person should obtain the incident
number and notify their supervisor to
complete the supervisor section of the report.
Timeframe for Submission
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Level II Reports
IRIS report must be
appropriately submitted
within with in 72 hours
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Level III Reports
Verbal report
immediately to
Eastpointe Monitoring
IRIS report must be
appropriately submitted
within with in 72 hours
IRIS report must be
submitted within 72
hours to DMH/DD/SAS
What if IRIS is unavailable?
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Any time IRIS is unavailable for use, providers must
still meet the required timeframe for submission of
an incident.
Reports may be faxed to Eastpointe at 910-2987165.
Provider must enter into IRIS as soon as possible
after IRIS back available.
This is the only time paper reports will be accepted.
IRIS replaced the DHHS Incident and Death Report
(DMH/DD/SAS form QM02)
Don’t Forget to:
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Print a copy for your records and maintain the
incident report number.
Providers are required to complete mandatory items
based on the type of incident that occurred. Mandatory
items are indicated by red stars
beside the item. If
you can answer questions without stars, please
provide this information.
It is essential to save information at the end of each
information tab. It may take several seconds before
data saves. Click on each Save icon only 1 time.
Incident Report Number
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IRIS provides an Incident Report number for
each report in two ways:
1. Save the entire report after completing Provider
Incident Information, Incident Information,
Consumer Services and Consumer Treatment
section. Click “Finish” and the incident number
appears on the screen.
Incident Report Number (continued)
2. Once you have completed the entire
report, to include Supervisor Actions Tab.
Example of Incident Number
Important Facts about Incident Number
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Print a copy of the incident number for your
record.
There is only 1 number for each incident
report.
The Incident Number will not contain the
letter “O”. All letters are lower case.
Any “0” will be a numerical zero.
Comment Sections
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Comment
boxes are
located on
many tabs
for the user
to provide
brief,
specific
information
on a topic.
Enter Incident Comments
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To enter specific
comments, click on the
pencil and paper icon.
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Type your information
and use spell check
Click “Save”
After you save the
information, the paper
and pencil will change to
a check mark
IRIS Home Page
To Report An Incident
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Choices include:
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Enter a new incident: Click to enter a new Level II
or III incident.
View/Edit: For an existing report, enter the
Incident Number and Consumer’s last name.
Please note: If you do not print the Incident
Number, please call Eastpointe Provider
Monitoring Department to request the number be
sent to you.
Provider Information Tab
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Enter Corporation Name
Name and Title of Person completing form
Local facility/Unit/Group Home
Physical Address
Mailing Address, City, Zip Code
Phone Number
Fax Number
Email Address – If the provider agency does not have
an email address, provider will need to determine the
email address to which the agency will get information
regarding the incident. Please make sure the email
address is accurate.
Provider Information Tab (continued)
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Counties
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County where services are provided/Host LME:
Where the consumer receives services
County of Residence/Home LME: The county in
which the consumer legally resides.
IRIS will notify the Host and Home LME of the
Incident Report.
Incident Information
There are 2 tabs that have to be completed in
this section
A. Date and Location Tab
If there is an allegation against the facility,
check YES. The supervisor will have to
complete the HCPR Facility Allegation
section of the incident report.
B. Services Type Provided Tab
Consumer Information/Treatment
There are 2 tabs that have to be completed in
this section
A. Consumer Information Tab
B. Consumer Information-Treatment Tab
Consumer Information Tab
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Consumer Name
Address Where
Incident Occurred
LME Client Record
Number – If there is not
a LME number, use
your provider
identification number.
Consumer Date of
Birth, Gender, Height,
and Weight
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Date of Last 2 Medical
Exams
Diagnosis – select up to
5 different diagnosis,
starting with the primary
diagnosis. Include ALL
as applicable.
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This helps to aid
oversight staff in
determining the
appropriate response
needed.
Consumer Information Tab (continued)
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Medications: Click on
the pencil icon to enter.
Include Name, Dosage,
Frequency of the
medication and the
reason the consumer is
taking the medication.
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Adjudicated
incompetent?
TBI recipient?
Receives CAP-MR/DD
funding?
MFP program?
Receive ICF-MR/DD?
Consumer Information-Treatment Tab
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Did this incident result in or is it likely to result
in permanent physical or psychological
impairment? If reporting a death, select “No”.
Has this incident resulted in or is it likely to
result in a danger to or concern to the
community or a report in a newspaper,
television or other media?
Consumer Information-Treatment Tab
(continued)
Was the consumer treated by a licensed
health care professional for the incident?
Do not include visits to a hospital ER if the
person received no treatment. Refer to
the definition of more than just First Aid
found in the Incident Response Manual.
If hospitalized, was it for a medical condition?
Was if for a MH/DD/SA issue?
 Opioid – Questions relate only for consumers
receiving Opioid Treatment.
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Consumer Information/Services Tab
There are 6 tabs in this section:
 MH/DD and/or SA Tab (3 separate tabs)
 Hospital Discharge Tab
 Last Appointment Tab
 Associated Incidents Tab
Type of Incident
Type of Incident
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Choose which type you are
reporting
Choices are:
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You must have at least 1
type of incident
Death
Restrictive Intervention
Injury
Medication Error
Allegation of Abuse,
Neglect, or Exploitation
Consumer Behavior
Suspension, Expulsion
Fire
Other
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You must include pertinent
details in the “Incident
Comment Tab” relevant to
the incident.
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Death Tab
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Manner of Death
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Choose one:
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Terminal Illness/Natural Cause
Accident
Homicide/Violence
Suicide – indicate method from drop down box
Unknown
Consumer Deaths
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Report ALL consumer deaths whenever you
become aware, even if it did not occur while
the individual was under your care.
Cause of Death by Natural Cause or
Terminal Illness should be documented by a
physician, Medical Examiner or Death
Certificate.
Level III Deaths
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Will include:
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Accident
Homicide/Violence
Suicide
Unknown Cause of
Death
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Requirements of All
Level III Deaths are to
obtain a copy of the
Medical Examiner’s
(ME) report and/or
autopsy report.
This is in accordance
with 10A NCAC 26C
.0303 (f) (3).
NOTE:
The web address for requesting a free
copy of ME report is:
http://www.ocme.unc.edu/docrequest.sht
ml
Make sure to complete all information on the
request and request all 3 documents.
NC OCME Document Request (only for NC Deaths Since 1975)
We are accepting on-line document requests, but cannot currently return all documents in an electronic format. Therefore, we must have a US mail address. Please also provide an
email address in case we need to contact you about your request. If you do not have an email address, call us at (919) 445-4410 to request a document.
Your Name and Address
First
Last
Name
*
* Required
Agency /Address Line 1 *
Address Line 2
City * State * Zip *
Telephone
Email Address
If you provide an email address, it ill be used for all of the documents that we can currently send electronically. You may need to
add documents@ocme.unc.edu to your address book to allow the documents to get past your spam filter.
The Decedent
Name of Decedent*
County of Death*
Date of Death*
Documents Requested *
Investigative Report
Autopsy Report (May not exist on every case)
Toxicology Report
SUBMIT
RESET
Consumer Death
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Providers must update the incident report,
even if the level does not change.
Updated information should be entered in
IRIS, documenting the reason for ReSubmission (in Supervisor Action Tab).
Attach copies of reports, Death Certificate
and/or other documents.
Level III Process
For Level III incidents that did not occur while the
consumer was receiving a service or was on the
provider’s premises, the responsible LME’s may
continue to request detailed information regarding
services if this information is not already provided in
the incident report. (See Attachment B: Suggested
Questions for Level III
Incidents.)
Manner of Death Tab
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If manner of death is unknown, check
“unknown cause”. Once the death is verified
via ME report and/or death certificate, the
cause of death has to be updated and the
report re-submitted.
Restrictive Intervention
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Report any restrictive intervention when:
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Use of unplanned, emergency situation.
Planned, but administered improperly or without
proper authorization, staff use without proper
training, or for longer than the authorized time.
Planned, but resulting in discomfort, complaint,
death or injury requiring treatment by a licensed
health care professional.
Restrictive Intervention
There are 9 Tabs in this section if IRIS requires
based on your responses.
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General 1 Tab
General 2 Tab
Status Check Tab
Staff Involved in
Restrictive Intervention
Debriefing Tab
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Person Centered
Planning 1 Tab
Person Centered
Planning 2 Tab
Person Centered
Planning 3 Tab
Follow-up Plans Tab
Injury
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There are 3 Tabs in this
section
Must complete for injuries
when the injury requires
more than First Aid
treatment.
The definition of First Aid is
listed in the Incident
Response and Reporting
Manual February 2011,
Appendix XI (page 29).
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3 Tabs include:
 Injury Description Tab
 Injured Body Parts Tab
 Injury Due to Tab
Medication Error
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Report all medication errors.
In cases of medication errors, the consumer’s
physician or pharmacist should be notified
immediately of any error, as required by 10A
NCAC 27G. 0209(h).
If the physician or pharmacist does not
believe the error is a threat of health or
safety, document the error as a level I.
Level I Medication Error
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Level I documentation should indicate the
following:
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The type of error,
Name of the physician or pharmacist consulted,
The statement made by the physician or
pharmacist about the error,
Date and time of the contact, and
Name of the person making the contact.
Level II Medication Error
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If the physician or pharmacist does believe the error
is a threat of health or safety, document the error as
a level II or III.
Ensure medical attention is provided as necessary
and recommended.
If after the medication error the consumer shows
any side effects or distress, seek immediate medical
attention.
Report all Level II and III errors in self administration
of medications within 72 hours of learning of the
incident, even if it did not happen while actively
engaged in providing services.
Medication Errors
Report the following:
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Missed dose
Wrong dosage
Dose preparation error
Wrong time
Wrong Administrative
technique
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Dose given to wrong
consumer
Wrong medication
Loss or spillage
Refusal
Other
Alleged Abuse, Neglect or Exploitation
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Complete this section for any allegation or suspicion
that a consumer has been abused, neglected or
exploited.
Report all suspected or alleged cases of abuse,
neglect or exploitation of a child or disabled adult to
DSS pursuant to GS 108A Article 6, GS 7B Article 3
and 10A NCAC 27G .0610
IRIS reports must be submitted.
IRIS does not submit reports to DSS. The provider
is responsible for contacting DSS to make the
report.
Reports made to DSS
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Always ask DSS to follow up with provider
agency in writing of the status of the report
and findings of the report is accepted
Attach DSS letter(s) in IRIS
Allegations against staff
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Reports must be sent to DHSR Health Care
Personnel Registry regarding an allegation
against an unlicensed staff in a licensed or
unlicensed facility should be submitted within
24 hours or the agency becoming aware of
the incident.
If the allegation is against a staff, the
Supervisor must complete the HCPR Facility
Allegation section of the Incident Report.
Consumer Behavior
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Types of consumer behavior:
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Any sexual, aggressive or destructive behavior
that involves a report to law enforcement, a
complaint to an oversight agency, including LME,
DSS, DHSR or DMH/DD/SAS
A potentially serious threat to the health or safety
of self or others
Consumer Behavior (continued)
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Report to the LME any acts that are reported
to law enforcements for:
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Incidents occurring while actively engaged in
providing services
Incidents related to individual’s treatment
When you learn of legal involvement of the
individual
Consumer Behavior (continued)
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Consumer Absence
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Any absence over the time specified in the PCP
Any absence that may or may not require police
contact
If an Amber or Silver Alert is issued, report as a
Level III. Alert appropriate agencies ASAP
Suspension or Expulsion
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When a consumer is suspended or expelled
from services
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Indicate the length of the suspension
Fire Information
Report as Level II or Level III when:
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there is any injury,
Consumer faces a threat to health or safety, or
Fire has an impact on public confidence
Authorities Contacted
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Check the box beside any individuals or
agencies that you have notified of the
incident, such as DSS, Law Enforcement,
Parent Guardian, etc.
Include the Contact Name, Phone Number
and Date of Notification
Provider Incident Comments
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These comments are public comments for IRIS
users ONLY
Comment Title – for example, Provider Detail of
Incident
Text – Include all information you want to document
about the incident. Be very clear and concise.
Paint a picture of what happened with the incident.
Check Spelling
Save by clicking “Save” button
Supervisor Actions
There are 4 Tabs in this section
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Level of Incident Tab
Cause of Incident Tab
Incident Prevention Tab
Incident Submission Tab
Level of Incident
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IRIS will determine the level based on the
information entered. This screen will
automatically show the level of II or III.
Cause of Incident Tab
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Describe what steps you have taken to
determine why the incident occurred and
what you have discovered.
Describe why the incident occurred – not
what happened. That should have been
described in the Provider Comment Section.
Incident Prevention Tab
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Provide a short description of actions that you
have taken or plan to take to prevent future
incidents of a similar nature.
Don’t just refer to “Agency Policy and
Procedure”.
Incident Submission Tab
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Upon submission, IRIS will notify Host/Home
LME, DMH/DD/SAS will be notified of Level
III incidents.
IRIS will notify Division of Health Service
Regulation (DHSR) of any level III deaths that
occur in a 122C licensed facility.
IRIS will notify DHSR Health Care Personnel
Registry (HCPR) of any level II or III
allegation of abuse, neglect, or exploitation
against an unlicensed staff member.
Incident Submission Tab (continued)
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Name, Title, Phone Number and email address of
Supervisor. This needs to include the working title,
not degrees and/or licenses
IRIS Agency Notification – Iris will provide a listing of
agencies notified based on the details provided.
Resubmission of Incident – When resubmitting the
report, enter explanation.
Attestation – By checking the box, you are affirming
the information is true and an accurate account of
the incident.
Do not click on Submit Incident box a second
time…be patient.
Attached Documents
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Attach documents that have been uploaded
from a computer into IRIS
Examples may include Medical Examiners
Report, Death Certificate, DSS Letters, etc.
When Attaching
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Follow All HIPPAA and Confidentiality Rules
Choose a Title
Click Browse and open the document you
want to attach. This will place the name of
the file into the Locate Attachment box
Click “Add Attachment(s)” and the documents
will be added to the report under “Attach
Documents” box
To View Attachment
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Click on Attach Documents Menu Button
In the list of documents click on the title and
click “Select”
Click on “Display Attachment”
Printing Incident
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Check items that you would like to print.
You may “Select All”
To print, click on the printer icon
An error occurred in IRIS

What do I do?
Copy the error message that you receive
Paste it in an email
Send to providermonitoring@eastpointe.net
Quarterly Reports
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Form must be submitted by the 10th of the
month following the end of the quarter
Providers required to submit aggregate data
on Level I incidents quarterly that involve:
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Restrictive Interventions
Medication Errors
Search and Seizure
What/Where to report

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Report to host LME
Total number of incidents
Unduplicated count of consumers involved
Highest number of incident for any one consumer
Brief narrative summarizing patterns or trends
(should be documented thru QA/QI process)
Brief narrative summary of QA/QI efforts to address
improvements identified.
Reporting Requirements

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Agencies are required to submit per Rule
Requirement (10A NCAC 27G .0604)
Tied to monitoring of agency
Submitting Quarterly Reports
Submit Quarterly Report through the Forms
Desk at
https://fd10.formdesk.com/eastpointe/Provider_
Quarterly_Incident
Or by visiting Eastpointe website at
www.eastpointe.net click on “For Provider
Community”, “Web Submission Form” and
“Quarterly Incident Report (QM11)

Other ways to submit
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Quarterly Incident Reports may also be faxed
to 910-298-7165 Attention - Susan Bryan
mail to: Eastpointe
500 Nash Medical Arts Mall
Attention Provider Monitoring
Rocky Mount, NC 27804
or emailed to
providermonitoring@eastpointe.net
Back-Up Staffing (NC Innovations
Waiver)

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To meet the needs of the participant to
ensure health and safety
Failure to provide back-up staff is considered
a Level I Incident per the NC Innovations
Waiver
The incident report is completed even if the
participant/family declines the back-up staff
offered
Back-Up Staffing (NC Innovations
Waiver) (Continued)


Level I form can be located in the NC
Innovations Waiver Manual (Appendix S)
http://www.ncdhhs.gov/dma/lme/Final_NC_In
novations_Manual_06252012.pdf
Incident report includes:
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Description of Incident
How the pariticpant was affected
How time was covered
Follow up Provided
Back-Up Staffing (NC Innovations
Waiver) (Continued)
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Follow-up provided should be accompanied
by documentation that supports intervention
and its effectiveness
Follow-up documentation should be
submitted with the incident report
Back-Up Staffing (NC Innovations
Waiver) (Continued)

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The Level I report must be submitted within
72 hours
Reports can be faxed to 910-298-7165
Back-Up Staffing Incident Reports are not to
be included in the Quarterly Incident Report
Summary.
Helpful Websites
IRIS Website:
https://iris.dhhs.state.nc.us/
IRIS Practice Site
https://irisuat.dhhs.state.nc.us/
IRIS Manual
http://www.ncdhhs.gov/mhddsas/statspublications/m
anualsforms/iris6-4-10dhhsmanual.pdf
Helpful Websites (continued)
Incident Response Manual
http://www.ncdhhs.gov/mhddsas/statspublications/m
anualsforms/incidentmanual2-25-11.pdf
Quarterly Incident Report
http://www.ncdhhs.gov/mhddsas/providers/NCi
ncidentresponse/qm11formproviderreport108-10.doc
Helpful Websites (continued)

Medical Examiner’s Report, Autopsy
Report or Toxicology Reports can be
obtained at:
http://www.ocme.unc.edu/docrequest.shtml

Restrictive Interventions
http://www.ncdhhs.gov/mhddsas/statspublicatio
ns/manualsforms/aps/apsm95-2clrights703.pdf
Helpful Questions Document


MH/DD/SAS website has generated a FAQ
document that may be helpful with questions
http://www.ncdhhs.gov/mhddsas/providers/N
Cincidentresponse/iris-faq-condensed.pdf
One frequently asked question is, do
providers have to have a user ID and
password? The answer is No.
Email: providermonitoring@eastpointe.net
All questions and comments will be posted and sent out on the Eastpointe
listserv as a Q & A document.