HSD/MAD/QAB
Incident Management System
Why Report Incidents?
New Mexico State law mandates
requirements for reporting alleged
incidents.
Incident reporting is a mechanism to ensure
the health and safety of consumers receiving
Medicaid services.
Why Report Incidents?
Incidents are reported to improve
service quality by identifying issues or
areas of concern.
 An incident must be reported before it can be
investigated.
INCIDENT ANAGEMENT
PRINCIPLES
 All adults and children receiving Home and Community
Based 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
 Consumers, legal representatives, and guardians must
be made aware of and have available incident reporting
processes
 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.
New Mexico
Statutes/Regulations.
 In recognition of the need to report such
incidents, the State of New Mexico provides
statutes and individual program regulations
which define the expectations and legal
requirements for properly reporting consumerinvolved incidents in a timely and accurate
manner.
List of Statutes and Regulations

Adult Protective Services - NMSA 1978, Section 27-7-30
http://law.justia.com/codes/new-mexico/2009/chapter-27/article-7/
Department of Health - 7.1.13 NMAC
http://dhi.health.state.nm.us/elibrary/regs/7.1.13NMAC_Incident_REP_INTAKE.pdf

 Personal Care Options - 8.315.4.12 NMAC B. (14), (15)
http://www.hsd.state.nm.us/mad/pdf_files/provmanl/prov83154.pdf
CoLTS ‘C’ Waiver - 8.307.18.10 NMAC E.
http://www.nmaging.state.nm.us/pdf_files/CoLTS-providerpdfs/8_307_18_CoLTS_C_Regulations.pdf

Mi Via Waiver - 8.314.6 NMAC
http://www.hsd.state.nm.us/mad/pdf_files/provmanl/prov83146.pdf

HSD/MAD/QAB
Incident Management
System
 This presentation and the Incident Management Guide
describes the statewide reporting requirements for all
incidents involving consumers served under certain
Medicaid-funded, Home and Community Based service
programs.
 These programs include
• CoLTS ‘C’ Waiver,
• Personal Care Option Program (PCO)
• Mi Via.
What Types of Incidents
Are We Required to Report?
All incidents involving:
abuse,
neglect,
and exploitation,
natural or unexpected deaths,
emergency services,
law enforcement,
environmental hazards.
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].
Abuse
Consumer is threatened with being homeless or
placed in a nursing home.
 Consumer is pushed or roughly handled while
receiving care.

Abuse/Self Abuse

Abuse includes self abuse

Agencies may write in “self-abuse”

Self abuse will be documented in the
narrative section.
Self-Abuse
Consumer is doubling up on pain
medication and will not see the doctor.
 Consumer’s alcohol consumption results
in frequent ER visits or law enforcement
interventions.

Abuse/Caregiver abuse

Caregiver abuse is important to report
◦ Seriously impacts the delivery of services
◦ Isolates the consumer
Service coordinator must be notified
 Description of abuse will be documented
in the narrative section of the report.

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
NMAC].
Neglect
Caregiver/family do not provide sufficient
food or do not allow others to provide
food.
 Medical appointments and treatments are
routinely not attended.
 The home is not warm or cool enough.

Neglect/Self Neglect
•Neglect includes self neglect.
•Agencies may write in “self-neglect”.
•Self neglect will be documented in the
narrative section.
Self Neglect
Not eating enough to stay well.
◦ May be ill
◦ May believe someone is poisoning the food
 Refuses to bathe or change clothes.
 Forgets or refuses medications
 No heat or electricity because bills are not paid.

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].
Exploitation
Caregiver uses consumer’s debit card for
their own purchases
 People move into the home uninvited and
without paying for rent or utilities
 Caregiver convinces consumer to sign
timesheet for hours not worked

Deaths are categorized as:
Unexpected Death: is any death caused by an
accident, unknown or unanticipated cause.
Natural/Expected Death: is 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
diagnosis/condition

◦ Cerebral palsy, mental health diagnosis,
cognitive delay, brain injury, etc
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.
Other Reportable Incidents
(ORI) Include:
Emergency Services
Law Enforcement Intervention
Environmental Hazard
Emergency Services
Emergency Services refers to admission to a
hospital or psychiatric facility or the provision
of emergency services that results in medical
care which is unanticipated and/or
unscheduled for this individual and which
would not routinely be provided by a
community based service provider.
Emergency Services
report this:
911 is called and the consumer refuses to
be transported.
 The consumer gets sick at the store and
the caregiver takes them to the ER.
 The consumer goes to the ER and then
leaves after checking in but before being
seen.
 The ER releases the consumer without
providing any treatment.

Emergency Services
DO NOT report this:
The consumer is at the doctor, gets sick and the
doctor sends them to the ER.
 The consumer 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
is defined as:
Law Enforcement Intervention is the arrest
or detention of a person by law enforcement,
involvement of law enforcement in an
incident or event, or placement of a person in
a correctional facility.
Law Enforcement





Police are called to the consumers home because of a
disturbance (even if the consumer is not causing the
disturbance)
The consumer is incarcerated.
The consumer 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 consumer is creating a
disturbance.
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 consumer
 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 Hazards is
defined as:
An unsafe condition which creates
an immediate threat to life or health.
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
Frayed, broken or trailing live wires
Clutter that impedes normal movement to bathrooms or exits.
Environmental Hazards

Drugs, guns and dangerous people
◦ Blatant illegal drug use or visible evidence of the
manufacture or sale of drugs
◦ Guns that are not locked up and/or are brandished by
the consumer or others in the home.
◦ The consumer or others in the home threaten, frighten
or harm caregivers or others providing services.
Submitting an Incident Report

Reporting abuse, neglect or exploitation to the MCO and HSD
does not relieve a provider of mandated reporting requirements
to Adult Protective Services (APS).

Incident reports must be submitted to the Consumer’s Managed
Care Organization (United Healthcare or Amerigroup) and
HSD/MAD/QAB within 24 hours of knowledge of the incident.
Report all incidents within 24 hours! If the incident occurs on a weekend or
holiday the incident must be reported on the next business day.

Description of the actual incident should always be provided by the
person with the most immediate knowledge of the incident.

All incidents pertaining to the HSD programs described in this
document should be reported using the Human Services
Department’s Incident Report form and are submitted to HSD via
FAX at (505) 827-3195.
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 is required to submit a completed
report.
The person with the most immediate
knowledge of the incident completes or
provides the information for Section 2.
Any staff, employee or consumer may
complete an incident report anonymously.
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.
APS Reporting Requirements
Providers shall report to APS:
Abuse,
Neglect,
Exploitation,
And deaths suspected to be a result of ANE.
Abuse, neglect, exploitation, deaths, emergency
services, law enforcement involvement, and hazardous
environments to: the appropriate MCO, (Amerigroup
or United Healthcare) and copies to HSD/MAD/QAB
(Report all incidents within 24 hours! (Next business day in the event of weekend or holiday).
APS REPORTING
GUIDELINES
 First and foremost, always ensure the safety of the
consumer!
 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
department.
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
warranted.
 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
Critical Incident
Reporting Flow Chart
HSD Incident Report Form
with Numbers and Instructions
HSD Incident Management
Sample Form
HSD Incident Management Form
Where Do We FAX
Incident Reports?
CoLTS ‘C’ Waiver,
Personal Care Option Program (PCO)
Mi Via.
APS Fax: 505-476-4913
CPS Fax : 505.841.6691
HSD/MAD/Quality Assurance Bureau
Fax: 505-827-3195
Amerigroup Fax: 1-866-920-8354
United Healthcare Fax: 1-866-751-2448
Where Do We FAX
Incident Reports?
Other programs:
DOH/DHI/IMB:
(Developmental Disability Waiver & Medical Fragile)
Fax: (800)584-6057
DOH/DHI/HFLC:
(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 CoLTS C, PCO or
Mi Via the report ALSO goes to HSD/MAD/QAB Fax: 505-827-3195.
Fraud
Alleged Fraud is reported as follows:
Follow the critical incident reporting process for all
cases of Abuse, Neglect and Exploitation
 Clearly mark as Exploitation/Alleged Fraud and fax form
to 505-827-3195
 You may also send an email to
matthew.quintana@state.nm.us
with “Alleged Fraud” in the subject line
 or call 505-827-3146.

HSD/MAD/QAB
Contact Information
If you have questions about any of the forms or the
content of this guide you may send a
Fax to: 505-827-3195
You will receive a response to your questions
within 48 hours.
Please allow additional time for weekends and
holidays.
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
consumers) 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 consultant, service
coordinator or guardian 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
services.
FAQ/Best Practices

What if the participant does not have a CoLTS
MCO (Amerigroup or United Healthcare)?
◦ Do not send the report to a Salud MCO (Presbyterian,
Lovelace, etc.)
◦ Send the report to the Consultant and APS if ANE,
and other agencies as defined by the Incident
Management Guide.
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.
◦ Anonymous reports are difficult to investigate and
follow up.
FAQ/Best Practices

I know that the state wants the person closest to the
event to complete the report, but sometimes they can’t.
What do I do then?
◦ Have the person complete the information for Section 2, then
the agency can complete and fax the report.
◦ Call the person and get as much information as possible and
complete the report.
◦ Complete the report and provide the person’s telephone number.
◦ Complete the report and state how you know what is reported.
You may get a call to explain how you know what
happened. If everything is on the report and it makes
sense, it saves a call.
FAQ/Best Practices

What do I do when a consumer calls in to report dangerous
behavior?
◦ If a consumer 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 consumer 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
interventions.
◦ The consumer should have a plan in their SSP that discusses what will occur
when they share information about harm.
◦ The consultant 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 on if it 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 screens incident reports according to a strict criteria. An report that is
screened out may be screened back in with additional information. An report
that is screened out may be investigated or followed up by other parties; this is
one reason reports are sent to different agencies.
~End~
Questions ?
HSD/MAD
Quality Assurance Bureau
Nancy Haas, 505-476-7265
HSD/MAD/QAB Fax: 505-827-3195