New Mexico Human Services Department

Critical Incident Management System
Revised November 1, 2013
 All adults and children receiving Centennial Care
services should be able to enjoy a quality of life that is
free of abuse, neglect, and exploitation.
 Staff must receive initial and ongoing training to be
competent to respond to, report, and document
incidents in a timely and accurate manner.
 Recipients, legal representatives, and guardians must be
made aware of and have available incident reporting
 Any individual who, in good faith, reports an incident or
makes an allegation of abuse, neglect, or exploitation
will be free from any form of retaliation.
 Quality starts with those who work most closely with
persons receiving services.
Incident Management
 This presentation describes the statewide reporting
requirements for incidents involving Home and
Community Based Services recipients enrolled in
Centennial Care -the new name for New Mexico’s
Medicaid Program.
Why Report Incidents?
New Mexico State law requires reporting
alleged incidents.
Incident reporting is a mechanism to ensure
the health and safety of recipients
receiving Medicaid funding.
Why Report Incidents?
Reporting incidents allows service delivery
agencies and Managed Care Organizations
(MCOs) to address concerns quickly for health
and safety.
Incidents are reported to improve
service quality by identifying issues or
areas of concern.
 An incident must be reported before it can be
New Mexico
 In recognition of the need to report such
incidents, the State of New Mexico provides
statutes and regulations which define the
expectations and legal requirements for
properly reporting recipient –involved incidents
in a timely and accurate manner.
Statutes and Regulations
 Adult Protective Services - NMSA 1978, Section 27-7-
 Centennial Care -State of New Mexico Human Services
Department Medicaid Managed Care Services
Agreement. 4.12.16 Critical Incident Management.
 Department of Health - 7.1.13 NMAC
What Types of Incidents
Are We Required to Report?
All incidents involving:
 abuse
 neglect
 exploitation
 death-expected or unexpected
 emergency services
L aw enforcement
 environmental hazards
 elopement and missing recipients
 Behavioral Health providers have an additional incident type to
be discussed in later slides.
Abuse is defined as:
Abuse means the willful infliction of injury,
unreasonable confinement, intimidation or
punishment with resulting physical harm,
pain or mental anguish [7.1.13 NMAC].
In the reporting system abuse includes:
• Sexual (directed at the recipient)
• Physical (directed at the recipient)
• Verbal (directed at the recipient)
• Self Injury
• Sexual Behavior Displayed (directed at the recipient)
• Rape (of recipient)
• Sexual (recipient towards others)
• Physical (recipient towards others)
• Verbal (recipient towards others)
• Attempted Suicide
• Type not specified
• Not specifying the type will likely generate a call for more information.
Recipient is threatened with being homeless or
placed in a nursing home.
 Recipient is pushed or roughly handled while
receiving care.
 Recipient is sexually assaulted.
 Recipient is made to do without food, water, or
bathroom access as punishment.
Recipient is doubling up on pain medication
and will not see the doctor.
 Recipient’s alcohol consumption results in
frequent Emergency Room (ER) visits or law
enforcement interventions.
 Recipient threatens or attempts suicide
 Includes cutting self, banging head repeatedly
or stepping into traffic.
Abuse/Caregiver abuse
Caregiver abuse is important to report.
◦ Seriously impacts the delivery of services
◦ Isolates the consumer
Service coordinator/consultant must be
 Description of abuse will be documented
in the narrative section of the report.
Caregiver abuse
Sexually harasses caregivers.
 Threatens caregivers or their families.
 Consistently uses racial or ethnic slurs when
talking to caregivers.
 Physically pushes, hits or throws things at
Neglect is defined as:
Neglect means the failure to provide goods
and services necessary to avoid physical harm,
mental anguish, or mental illness [7.1.13
In the reporting system neglect includes:
• Insufficient staffing
• Staff not performing assigned tasks
• Care not being given by family or others who have
agreed to provide support
• Self Neglect (refuses food, hygiene, medications
including substance abuse and dangerous behavior)
• Self Neglect (refusing services)
• Type not specified.
• Not specifying the type will likely generate a call for more
Agency frequently fails to provide services that have
been authorized.
Staff show up but do not do assigned tasks.
Family or others who have promised support
◦ do not pay the bills
◦ do not purchase sufficient food and supplies
◦ do not arrange or transport to needed medical care
◦ do not provide support as agreed in the personalized
service plan for the recipient. (staying overnight,
bathing after paid caregiver hours, preparing meals,
Self Neglect
Does not eat enough to stay well.
◦ Can no longer prepare appropriate meals.
◦ Thinks the food is being poisoned.
◦ Forgets to eat.
Refuses to bathe or change clothes.
 Forgets or refuses medications or takes too many at a
 No heat or electricity because bills are not paid.
 Brandishes weapons at neighbors or caregivers.
 Shoplifts.
 Consistently refuses to allow services to be delivered.
Exploitation is defined as:
Misappropriation of property (i.e.
exploitation) means the deliberate
misplacement of consumer’s property, or
wrongful, temporary or permanent use of a
consumer’s belongings or money without the
consumer’s consent [7.1.13 NMAC].
Caregiver uses recipient’s debit card for their own purchases.
People move into the home uninvited and/or without paying for
rent or utilities.
Caregiver convinces recipient to sign timesheet for hours not
Recipients medications are frequently missing.
Caregivers or others are taking the recipient’s property (this is
exploitation even if the recipient is offering it under duress or as a
result of a medical condition such as dementia).
Caregiver borrows money and does or does not pay it back.
Recipient is encouraged or pressured into providing sexual services
with or without pay.
Incidents of exploitation may be also
reports of alleged Fraud. (See slides 57-59)
 The Alleged Fraud field is selected if a
report concerns Medicaid funding that
has been paid for services not rendered
(e.g. claiming time for work not
completed) or for services diverted to
inappropriate use(e.g. sale of Medicaid
paid goods)
Abuse, Neglect and Exploitation
Agencies are responsible to report
immediate jeopardy incidents to Adult
Protective Services (APS) immediately by
phone or fax.
 MCOs will report all ANE incidents to
APS daily.
 Any report made to APS must also be a
report completed and submitted into the
HSD website.
Unexpected Death: any death caused by an
accident, unknown or unanticipated cause.
Natural/Expected Death: any death caused by a
long-term illness, a diagnosed chronic medical
condition, or other natural/expected conditions
resulting in death.
Unexpected Deaths
 Homicide
 Suicide
 Accident
 Death unlikely to be attributed to
Expected Deaths
 Hospice
 Terminal conditions
◦ End stage renal disease
◦ Multiple strokes/heart attacks
◦ Advanced age (more than 90 years old)
Deaths occurring in a facility while in
treatment for disease
If the recipient is in Hospice care the
agency will follow the hospice plan of
care and will not file neglect for refusing
food, medications etc.
 A death under the care of a Hospice
agency is considered a natural/expected
Deaths are tracked by the MCOs for
opportunities to improve services and
outcomes of treatment.
 Agencies may be requested to provide
additional information if needed for these
The criteria governing the selection of
Unexpected vs. Natural/Expected Deaths is
Unexpected Deaths require investigation:
◦ Additional information may be gathered to
explain the death which is added to the report.
◦ A referral to Office of Medical Investigation may
be appropriate.
◦ Medical records may need to be reviewed.
Other Reportable Incidents
(ORI) Include:
Emergency Services
Law Enforcement Intervention
Environmental Hazard
Emergency Services
•Emergency Services refers to:
•A 911 call to the home or location of the recipient
(whether or not the recipient is transported)
•Unanticipated admission to a hospital or psychiatric
•Emergency room visits whether taken by caregiver,
family or EMT (Emergency Medical Transport)
Emergency Services
Examples of reportable Emergency Services:
911 is called and the consumer refuses to be transported.
The recipient gets sick at the store and the caregiver
takes them to the ER.
The recipient goes to the ER and then leaves before
being seen or treated by medical staff.
The ER releases the recipient without providing any
Emergency Services
Examples of NON REPORTABLE Emergency Services:
The recipient is at the doctor, gets sick and the doctor
sends them to the ER.
The recipient is admitted to the hospital for a scheduled
treatment or observation.
An ambulance is used for transportation for either a
scheduled physician visit or to the hospital for a
scheduled procedure.
Law Enforcement
Law Enforcement Intervention refers to:
the arrest or detention of a person by law enforcement
involvement of law enforcement in an incident or event
transportation of a person to a hospital or correctional
Law Enforcement
 Police are called to the recipient’s home because of a
disturbance (even if the consumer is not causing the
 The recipient is arrested and/or incarcerated.
 The recipient is picked up for a bench warrant or parole
violation (even if they are released).
 The police are called to do a ‘well check’ (even if they find
them ‘well’).
 The police are called because the recipient is creating a
 A person is detained in Protective Custody.
 A person is transported by police to a hospital or mental
health facility, voluntarily or involuntarily or through an
involuntary treatment court order.
Law Enforcement
Law Enforcement involvement for a caregiver is NOT an a
reportable incident.
However, there may be a reportable incident if
• The caregiver has harmed or robbed the recipient.
• The caregiver being detained or incarcerated results in
services not being delivered.
• The caregiver is also the natural support and is not
available to provide health and safety supports.
Environmental Hazard
Environmental hazard refers to:
• An unsafe condition which has created or may
create a threat to life or health or safety for the
recipient or the caregiver.
Environmental Hazards
 A fire or flood has created a hazard in the home.
 Animals are out of control at the home
◦ Threatening services
◦ Creating more waste that can be cleaned timely.
 Lack of repairs that create hazards
◦ Lack of water, electricity, heat that was in place previously
 Wood heat or hauled water is not considered a hazard.
◦ Holes in the floors
◦ Roofs that leak
◦ Windows and doors broken
◦ Debris not cleared.
 Foul smells, piles of garbage, standing dirty water, etc..
 Clutter that impedes normal movement to bathrooms or exits.
Environmental Hazards
Examples continued:
Drugs, guns and dangerous people!
• Blatant illegal drug use or visible evidence of the
manufacture or sale of drugs.
• Guns that are not secured and/or are brandished by
the recipient or others in the home.
• The recipient or others in the home threaten, frighten
or harm caregivers or others providing services.
Environmental Hazards
The following are NOT environmental hazard
 The home is heated with wood (and has a
functioning stove and ventilation)
 The home does not have running water (and the
home has systems to provide safe potable water
for use).
 Clutter is contained and does not impede
function of the home or safe passage of the
individual and caregiver.
◦ Primarily a Behavioral Health incident type
◦ Occurs when someone is required to be
somewhere and then leaves without permission
or alerting others
◦ Used for those recipients who leave without
intent to stay gone. May be lost or unaware of
their surroundings.
 Not to be used for those who have intentionally left
their residence without telling anyone. Those reports
will be filed as “missing” without a secondary incident
Submitting an Incident Report
Incident reports must be submitted for recipients of Centennial
Care through the web site for the HSD Incident Reporting
 Incidents must be reported within 24 hours of knowledge of the
 Incidents must be reported accurately.
 Incidents must be reviewed by the agency and the MCO to
determine if follow up is needed.
Submitting an Incident Report
 Agencies that do not comply with incident
reporting requirements are in violation of state
statute and Medicaid regulations, and may be
sanctioned up to and including termination of
their provider agreement by an MCO or by the
HSD, Medical Assistance Division.
Who Completes an Incident report?
The agency delivering an authorized service submits the incident
report within 24 hours of knowledge of the occurrence.
The MCO submits an incident within 24 hours of an occurrence
discovered during MCO/recipient activities (assessment, phone call,
The Financial Management Agent (FMA) submits an incident for
recipients with Self Directed Services if the FMA discovers an alleged
incident or receives a call from the recipient.
An interested person may call or write an agency or MCO and report
an incident anonymously. The agency or MCO will then submit an
incident based on the information received.
Self Directed Services
Incident Reporting for recipients of
Centennial Care Self Directed Services
follows the same processes and
procedures as other incident
 Reports will be made by the MCO
Support Broker or Service
Coordinator, any provider of services
or by Fiscal Management Agent staff.
Self Directed FMA is ‘Special’
The FMA is unique when reporting incidents:
◦ The FMA does not deliver services.
◦ The FMA does not maintain a ‘primary file’.
◦ The FMA does not directly address any of the issues
◦ The FMA is the only agency that ALL Self Direction
recipients utilize.
 Maintaining accurate and complete information is a
◦ IF the FMA does not have the required information,
they will state “not available to FMA”
 Medications, diagnoses, etc
◦ The FMA must share all the information they DO have.
 Name of MCO
 Accurate demographics
◦ SS#
◦ Address, phone, etc
◦ Date of birth
◦ Name and phone # of employee/caller
Behavioral Health
Critical Incidents
Behavior Health Services are integrated into
Centennial Care.
 Behavioral Health Agencies have additional
functions to complete when submitting a
 Critical Incidents submitted to the database by
Behavioral Health Providers include those
reported by the provider and those reported to
the provider by agency staff or family.
Behavioral Health
Critical Incidents
When a Behavioral Health (BH) provider
opens a report to complete, the agency’s name
will self populate.
 The agency is recognized as a BH provider
and two functions become enabled:
◦ A diagnoses dropdown box
◦ A treatment location type drop down box
◦ Also one additional incident type becomes enabled.
Behavioral Health
Critical Incidents
Diagnoses Drop Down
◦ Only a primary diagnoses will be selected
◦ All other diagnoses relevant to the report can be
added to the free text diagnoses field.
Treatment Site Drop Down
◦ This is the site/service that the reporter works for at
the time of the incident.
◦ The additional provider information (address,
phone) will be entered in the appropriate fields.
Behavioral Health
Critical Incidents
Many people receiving Centennial Care
services have behavioral health diagnoses.
 Only the Behavioral Health Agencies will enter
BH Critical Incidents.
◦ When other Centennial Care agencies open a
report to complete, the BH functions are not
available and the report can be completed as usual.
Behavioral Health
Critical Incidents
An incident that is reported by a BH provider
may be related to incidents for the same
recipient submitted by other Centennial
providers. These are not duplicates.
Reporting to
Adult Protective Services
The MCOs report all incidents of Abuse,
Neglect and Exploitation (ANE) which have
been submitted to the HSD Critical Incident
website to APS within 24 hours.
 If an agency directly reports a case to APS (and
includes all required information) the agency
will be able to get information about the report
from APS. The agency is still required to report to
the HSD Critical Incident Website.
The Adult Protective
Services Act
Mandates any person having reasonable cause
to believe an incapacitated adult is being
abused, neglected or exploited shall
immediately report that information to Adult
Protective Services.
If the recipient is under 18 years of age a report of Abuse, Neglect or
Exploitation must be reported to Child Protective Services (CPS)
Fax : 505.841.6691
APS Reporting Requirements
Abuse, Neglect, Exploitation(ANE),
And deaths suspected to be a result of ANE.
Abuse, neglect, exploitation, deaths, emergency
services, law enforcement involvement, and hazardous
environments shall also be submitted to the HSD
reporting website.
Report all incidents within 24 hours!(Next business day in the event of weekend or holiday).
 First and foremost, always ensure the safety of the
 The New Mexico Adult Protective Services (APS)
Act mandates: Any person having reasonable cause to
believe an incapacitated adult is being abused, neglected, or
exploited shall immediately report that information to the
Deaths Reported to APS
Deaths that are suspected of being related to
abuse or neglect must be reported immediately
to APS.
 Deaths that are the result of natural causes
and/or are expected do not need to be reported
to APS.
 If the death occurs outside of a medical facility,
local law enforcement must be notified.
APS Procedure
 APS will screen all incident reports and make a
determination whether investigation is
 If the incident involves a criminal act, local law
enforcement must be notified immediately.
 Law enforcement must be notified by the
person reporting the incident.
 When the incident is reported to APS, if law
enforcement has not been notified APS will
notify law enforcement.
Adult Protective Services
Statewide Central Intake
Incidents involving suspected/alleged abuse, neglect, and
exploitation must be referred immediately to:
Telephone: 866.654.3219
FAX: 505.476.4913
(The MCO for a Centennial Care recipient will report all ANE reports
to APS within 24 hours of review of the online submission)
If the recipient is under 18 years of age a report of Abuse, Neglect or
Exploitation must be reported to
Child Protective Services (CPS)
 Fax : 505.841.6691
Where Do We Send
Incident Reports?
Centennial Care
HSD/MAD/Quality Bureau:
APS Fax: 505-476-4913
If the recipient is under 18 years of age a report of Abuse,
Neglect or Exploitation must be reported to
Child Protective Services (CPS)
Fax : 505.841.6691
Where Do We FAX
Incident Reports?
Other programs:
(Developmental Disability Waiver & Medical Fragile)
Fax: (800)584-6057
(Licensed Home Health, Assisted Living Facilities and Nursing Facilities)
Fax: (888)576-0012
If the Home Health patient or the Assisted Living resident is a member of Centennial Care the report
Report incidents of abuse, neglect and exploitation of any individual outside of Medicaid programs to
APS as mandated by state statute
Alleged Fraud is reported as follows:
 Follow the critical incident reporting process for all
cases of Abuse, Neglect and Exploitation.
 Select “Alleged Fraud” check box within the form.
 Complete any MCO required reporting to the Managed
Care Organization in which the recipient is enrolled.
 The MCO will review and investigate and report to the
state the results of investigations.
Examples of Fraud
 The consumer and the caregiver agree to sign off on
timesheets that do not represent time worked.
 The caregiver has the consumer sign timesheets ahead
of time and turns them in including time not worked.
 Billing is submitted when consumer is out of town or in
the hospital.
 Consumer is selling Medicaid goods (Depends, DME or
 Caregiver turns in timesheets for delivery of services to
more than one consumer for the same time/date.
Examples of wrongdoing that are NOT fraud.
These must be reported to the HSD Critical Incident website as
exploitation but do not constitute fraud; the alleged fraud field will
not be selected.
The caregiver takes money from the consumer’s home.
 The consumer uses their Social Security check for
drugs or gambling.
 The caregiver uses the consumer’s debit card for their
own purchases.
 Consumer is intimidated into turning over the deed to
their home.
HSD Incident Management System
FAQ/Best Practices
What about multiple reports?
 What about the consumer who demands that a report be
created about the same thing over and over? (e.g.
Accusing a previous caregiver of stealing)
Develop a policy and procedure for the organization (and shared with
recipients) that states multiple report requests will be reviewed and
will be reported to the state on a monthly basis as one report.
Make a documented call/memo to the consumer’s service coordinator
and guardian (if applicable) sharing the issue and requesting
assistance for the consumer to understand the purpose of incident
reporting and to assist the consumer to resolve any issues in
FAQ/Best Practices
What if the recipient does not have an MCO?
◦ Select “Not Medicaid Funding” or “Fee for Service” (as
appropriate) from the MCO drop down choices.
◦ For Native Americans who “OPT OUT”, use “Fee for
Service” as a drop down choice.
◦ If “Not Medicaid Funding” is chosen, be prepared to answer
questions from HSD.
 All Centennial Care recipients will select an MCO upon eligibility
FAQ/Best Practices
Can I complete a report anonymously?
◦ If you are working for an agency, you must complete
the report with your name and phone number and role
with the agency.
◦ You may complete a report anonymously only if you
are reporting as a private citizen who does not have a
role in the services for the consumer.
◦ You may file a report based on an anonymous call.
◦ Anonymous reports are difficult to investigate and
follow up and maybe screened out by the MCO and
FAQ/Best Practices
What do I do when a consumer calls in to report dangerous
◦ If a recipient calls and talks about hurting themselves or others you must
have an appropriate and consistent response.
◦ Your agency must have a policy and procedure for addressing these kinds of
calls. This policy must be shared with the recipient when they enroll in your
agency and when you take the call about the concerning behavior.
◦ This policy will describe the options you will take which may include calling
authorities or a counselor, redirecting to a crisis hot line or other
◦ The recipient should have a Care/Treatment plan that discusses what will
occur when they share information about harm.
◦ The service coordinator must be immediately informed.
FAQ/Best Practices
Why doesn’t APS put the person into a nursing home?
 Why doesn’t APS ever call me back?
 How do I know what APS found out?
◦ APS may be able to assist a vulnerable adult to get a guardian or may be able to do
an emergency support situation. They can assist the courts to determine
competency. They do not make permanent decisions about people’s lives.
◦ APS can tell a reporter of an incident if the report was received. They may have
information including if the call was screened in or out. And if APS needs additional
information or assistance with an investigation the reporting agency may be
involved. APS has very strict procedure about sharing investigations and outcomes.
APS will only do this if the reporters address and phone number is
clearly written on the report.
◦ APS screens incident reports according to a strict criteria. A report that is screened
out may be screened back in with additional information. A report that is screened
out may be investigated or followed up by other parties; this is one reason reports
are sent to different agencies.
Managed Care Organizations
MCOs are required to review and process all critical
incidents submitted to the HSD web system for their
enrollees within directed timeframes, including
reporting ANE to APS.
MCOs are required to submit all incidents they become
aware of through their activities with the recipients.
MCOs are required to train all staff who work with
recipients directly or indirectly on the principals and
practice of reporting incidents.
MCOs are accountable for reviewing and establishing
procedures for follow up including working with
recipients, APS, local law enforcement, tribal social
services and with the agencies that provide services.
Managed Care Organizations
MCOs are required to ensure that agencies who
subcontract to provide authorized services are
reporting incidents appropriately and collaborating
with follow up activities. This includes documented
training and technical assistance prior to any
 MCOs are required to track and trend critical
incident reports and report to the state as directed.
 MCOs report Critical Incident data and analysis to
the State monthly and quarterly. This includes reports
on the total Centennial Care population, on BH
critical incidents and on incidents involving recipients
of Self Directed Services.
Behavioral Health (BH) Critical Incidents
A report is considered a “Behavioral Health Report”
when submitted by a BH provider for a client enrolled in
Centennial Care.
A Centennial Care recipient who has a behavioral health,
mental health or substance abuse diagnosis whose
incident is reported by other providers is NOT
considered a BH incident and the report follows the
process required in this training.
BH Providers must report critical incidents as directed in
this training.
Behavioral Health Providers have additional information
they must include in the reporting system such as
selecting provider type. There are incident types that are
critical to BH reports.
Reports to the state by the MCOs for BH incidents
require BH providers to include accurate Diagnoses
Self Directed Services
Critical Incidents involving recipients who are receiving
Centennial Care Self Directed Services are reported
following the direction in this training.
Reporting an incident for this population requires that
the Medicaid category of eligibility (COE) be selected and
also that the Self Directed program be selected.
This population will be increasing dramatically with
Centennial Care and MCOs are required to track
incidents for this population for monthly and quarterly
reporting to the state.
Reports for this population will be submitted by the
agency that is providing the services, the consultant or
broker for the recipient and by the Financial Management
Agent (FMA currently XEROX) depending on who has
information regarding the incident.
Be accurate!
◦ Wrong information slows response to the issue and
may violate HIPPA regulations.
◦ Have the correct information easily available to the
Make sure the right people know about the
◦ APS gets all Abuse, Neglect and Exploitation.
 These are reported by the MCO or HSD to APS from
submitted reports. If you want APS to share any information
with you, you must call in the report with your agency name
and phone number. (See slide #38)
◦ Support Brokers and Service Coordinators need to
know to help.
Be comprehensive!
◦ Make sure you have included the names and
information needed to tell the story. The diary entries
are available for more detailed information or
Be Brief!
◦ ‘Just the facts, ma’m’ (or the allegations). Opinions and
information not regarding the event slow down the
Expect the call!
◦ Make sure your agency has all the back up
information and documentation of any follow up
activities done by the agency. Understand your
Contact Information
If you have questions about the website or the
content of this presentation you may email
You will receive a response to your questions
within 48 hours.
Please allow additional time for weekends and
Questions ?
Quality Bureau
Nancy Haas, 505-476-7265
Jeanne Cournoyer, 505-827-3109
Amy Salazar, 505-827-3170