IAD Form Training - Mercy Maricopa Integrated Care

Incident
Reporting
PM Form 7.4.1 - Required elements for complete and
accurate Incident/Accident/Death (IAD) Reporting
PDF incident/Accident/Death (IAD) Reporting
What you will learn from these slides:
1. Submission expectations and timeframes
2. Specific MMIC submission requirements
3. How to complete the updated PDF IAD form (Note: should a
required box be incomplete, the form will stop the final email
button from working until all data is entered; mandatory
boxes shown in red in this presentation)
4. What happens if the PDF IAD Report is incomplete, incorrect,
or missing data
PDF IAD Reporting – Pg 1:
This is what the first page of
the PDF IAD looks like. This
page will be broken down by
the 4 bracketed areas…
1. INSTRUCTIONS
2. MEMBER
INFORMATION (2
parts)
3. Diagnosis
4. RBHA
INFORMATION
PDF IAD Reporting – Pg 1: PDF IAD INSTRUCTIONS
1. The user of this form will need to have a minimum of Adobe Reader XI (11) in
order for it to function as intended. This is a free version of the Adobe Reader
available on the Adobe website.
2. All sections of the IAD report must be completed; use N/A or ‘none’ where
possible, but you may need to give your ‘best-guess’ for some dates as leaving
them blank will block your attempts to email the PDF IAD to MMIC. If the IAD
is hand written it must be neat and legible (and signed by Preparer and Clinical
Director), otherwise it may be returned for correction and resubmission.
3. MMIC requires a written report within 2 business days (48 hours) for all
serious, critical, unusual incidents.
PDF IAD Reporting– Pg 1: MEMBER INFORMATION
MEMBER INFORMAITON
•
•
•
•
Member Name is the name of the person who the PDF IAD is being completed
about.
Date of Birth is that person’s birth date (MM/DD/YYYY).
Age is the current age of that person.
Gender is selected by using the drop-down box provided…
*Please Note that all red boxes must be completed for PDF IAD to be
accepted. You will not be able to submit the PDF IAD if it is not complete;
you will be prompted to go back and complete the missing data.*
PDF IAD Reporting– Pg 1: MEMBER INFORMATION
MEMBER INFORMAITON cont.
•
•
•
•
•
•
•
CIS ID # is a random 10-digit number (usually not the BHMIS ID #); the MMIC Clinical
Liaison should include this # with the Referral Packet. Contact them if you do not have it
as you will need it for Billing and IAD Reporting.
AHCCCS ID is the 8 digit number that starts with an A.
Eligibility Status is selected by using the drop-down.
Category of BH fund is selected by using the drop-down.
History of COT at the time of the Incident (Court Ordered Treatment) is selected by using
the drop-down.
DDD is selected by using the drop-down (MMIC submissions are ‘No’).
CMDP is selected by using the drop-down (MMIC submissions are ‘No’).
PDF IAD Reporting– Pg 1: Diagnosis
Diagnosis
There is space for multiple Diagnosis Codes and Names (based on DSM V nomenclature)
for each PDF IAD. The first Diagnosis Code and Name are mandatory; other locations
should only be used if more diagnoses exist for the member.
•
•
•
Diagnosis Code is DSM Diagnosis # associated to the member’s diagnosis.
Diagnosis Name is the name of the DSM Diagnosis for the Code # identified.
Complete each Code/Name line as needed.
PDF IAD Reporting– Pg 1: T/RBHA INFORMATION
T/RBHA INFORMATION
•
•
T/RBHA- please use the drop down box and select “Mercy Maricopa Integrated Care”
for all individuals referred to you by MMIC.
Assigned GSA is the number 6 for Mercy Maricopa Integrated Care.
PDF IAD Reporting– Pg 2 :
This is what the second page of the
PDF IAD looks like. This page will
be broken down by the 3 bracketed
areas…
1. PROVIDER
INFORMATION
2. INCIDENT
INFORMATION
3. Location of the Incident
and Description of the
Incident
PDF IAD Reporting– Pg 2: PROVIDER INFORMATION
PROVIDER INFORMAITON
•
•
•
•
•
•
Provider Name – Please make sure to use the full agency name. Do not abbreviate.
License # is your location’s Behavioral Health license number.
Address is the Street, City, State and Zip Code of the specific site that is reporting
the incident.
Phone # is the phone number of the agency or specific site that is reporting the
incident.
Date of Last Visit With Clinical Team would be the date of the last contact with
someone from your agency; a date must be used in this format: MM/DD/YYYY.
Date of Last Visit With the BHP or PCP (psychiatrist or Primary Care Physician)
would be the date of the last contact with one of these, or state ‘unknown.’
PDF IAD Reporting– Pg 2 : INCIDENT INFORMATION
INCIDENT INFORMATION
•
•
•
Date of Incident is the actual date the incident being reported occurred (may be an
approximate date or time of year.
Time of Incident is the time that the incident occurred (may be approximate time of
day or mark ‘unknown’).
Date reported to the Provider- this is the date that the Incident was reported to the
Provider.
PDF IAD Reporting– Pg 2 : INCIDENT INFORMATION
INCIDENT INFORMATION
•
•
cont.
Location of the Incident– please report as best you can where the incident being
reported occurred using an address or description of where the incident occurred; at
minimum have a county or area.
Description of the Incident- Completely, clearly and accurately, report all pertinent
information related to the incident, including what led up to the incident.
PDF IAD Reporting– Pg 3 :
This is what the third page of the
PDF IAD looks like. This page will
be broken down by the 6 bracketed
areas regarding the Type of
Incident…
1. Mortalities
2. Serious/Critical Incidents
3. Member Rights Violations
4. Communicable Disease
5. HCAC/OPPC Incidents
(Level I Hospitals only)
6. Other Serious/Critical
Incidents
PDF IAD Reporting– Pg 3 : INCIDENT INFORMATION
INCIDENT INFORMATION cont.
Type of Incident
•
These first 5 Types of Incidents relate to the death of a person (Member).
PDF IAD Reporting– Pg 3 : INCIDENT INFORMATION
INCIDENT INFORMATION cont.
Type of Incident cont.
•
These incident types are the critical/unusual Incident types that are required to be
reported in writing, using the PDF IAD form.
- Note: AWOLs should be reported using this check-box (please do not indicate
AWOL using the Other box, unless you Agency does not fit what is offered here).
PDF IAD Reporting– Pg 3 : INCIDENT INFORMATION
INCIDENT INFORMATION cont.
Type of Incident cont.
•
These Types of Incidents are Member Rights Violations and are perpetrated by Adult/Staff
members (person in authority) on clients, and not peer-to-peer.
PDF IAD Reporting– Pg 3 : INCIDENT INFORMATION
INCIDENT INFORMATION cont.
Type of Incident cont.
•
Should a client, staff member or employee be found to have a communicable disease,
there are also requirements beyond submitting a PDF IAD. The next slide contains a
list of communicable diseases that should be reported to the RBHA, but there are other
instructions regarding necessary reporting of communicable diseases. Please see
bottom of the slide for more information. You will also receive a copy of this list for
your use.
PDF IAD Reporting– Pg 3 : INCIDENT INFORMATION
Type of Incident cont.
•
These 2 incident types are for Level 1 Hospital settings and should they occur, be described in
detail on page 3- Description of the Incident.
• Examples of an HCAC would be: Foreign Object Retained After Surgery; Air
Embolism; Blood Incompatibility; Stage III and IV Pressure Ulcers; Falls and
Trauma; including Fractures, Dislocations, Intracranial Injuries; Crushing Injuries;
Burns; Electric Shock; Catheter-Associated Urinary Tract Infection (UTI); Vascular
Catheter-Associated Infection; Manifestations of Poor Glycemic Control (including:
Diabetic Ketoacidosis, Nonketotic Hyperosmolar Coma, Hypoglycemic Coma);
Secondary Diabetes with Ketoacidosis, Secondary Diabetes with Hyperosmolarity;
Surgical Site Infection Following: Coronary Artery Bypass Graft (CABG) –
Mediastinitis; Bariatric Surgery; including Laparoscopic Gastric Bypass,
Gastroenterostomy, Laparoscopic Gastric Restrictive Surgery; Orthopedic
Procedures (including Spine, Neck, Shoulder, Elbow)
Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Total Knee
Replacement or Hip Replacement with pediatric and obstetric exceptions.
PDF IAD Reporting– Pg 3 : INCIDENT INFORMATION
Type of Incident cont.
Examples of an OPPC would be:
•
•
•
Wrong Surgical or other invasive procedure performed on a patient
Surgical or other invasive procedure performed on the wrong body part
Surgical or other invasive procedure performed on the wrong patient
PDF IAD Reporting– Pg 3 : INCIDENT INFORMATION
INCIDENT INFORMATION cont.
Type of Incident cont.
•
The Other line should be used to identify any other “serious, or critical” incident that do not fit
into one of the previously provided categories. Be specific and brief here, and explain in more
detail on page 3- Description of the Incident. Please refer to Definitions document.
There is no reason to report anything that is non-critical in writing (i.e.: nose bleeds,
contraband, witness to something, minor property damage, etc.
If your program does not fit the ‘Unauthorized Absence…’ checkbox offered above, you should
indicate ‘AWOL’ here.
PDF IAD Reporting– Pg 4:
This is what the forth page of the
PDF IAD looks like. This page will
be broken down into these 3 areas:
1.
2.
3.
Members Condition
Before & After the
Incident
Individuals who Witnessed
the Incident
Description of any Medical
Services Received
PDF IAD Reporting– Pg 4: Member’s Condition Before & After the
Incident
Members Condition Before & After the Incident
Describe both of the following for Before and After the Incident:
• Physical condition (defined as the condition or state of the body or bodily functionsrested, tired, agitated, tense, relaxed, etc.) and
• Behavioral condition (document the client’s behaviors – yelling, pacing, making fists,
shaking, hyper-vigilant, withdrawn, etc.)
•
Both of these conditions should be addressed, both before the incident and after the incident
occurred.
PDF IAD Reporting– Pg 4: Individuals who Witnessed the
Incident
Individuals who Witnessed the Incident
Please identify any witness to the incident and include the following information for each:
• Witnesses Name;
• Address (if known);
• Phone # (if known);
• and relation to the member for whom the PDF IAD is being completed.
PDF IAD Reporting– Pg 4: Description of any Medical
Services Received
Description of any Medical Services Received
Please include the following information related to Medical Services supplied to the person
(Member):
•
•
•
•
Date and time of Medical services;
Name of person who provided immediate attention;
Any sort of First-aid (from bandage to cold compress and beyond should trigger
completion of this box;
If Urgent Care, ER or hospital is used, please indicate their name and attach their
discharge paperwork (or write a summary of that document), if you have a copy, or
submit when you receive it.
PDF IAD Reporting– Pg 5:
Paste new snipit here
This is what the fifth page of the
PDF IAD looks like. This page
will be broken down into 4 areas:
1. Actions Taken and/or
Recommended
2. NOTIFICATIONS
3. PREPARER’S
SIGNATURE
4. Option buttons
PDF IAD Reporting– Pg 5: Actions Taken and/or Recommended
Actions Taken and/or Recommended
Please document the following:
• Any Provider Agency actions taken related to the incident being reported
• Recommendation of actions the Provider Agency will take to address this incident and to
keep similar incidents from occurring in the future;
• These Actions would include changes to Provider Agency policies or procedures; staff
training, or other performance improvement activities (may be more appropriate in
Clinical Director Review section).
PDF IAD Reporting– Pg 5: NOTIFICATIONS
Place new snipit here
NOTIFICATIONS
Agency
Please indicate which agencies were notified regarding this incident within a 24 timeframe.
PDF IAD Reporting– Pg 5: Preparer’s Signature
Place new snipit here
PREPARER’S SIGNATURE
Name & Credentials
• Please include the name and credentials (Degree; position at the Provider Agency, AZ State
License type, etc.) of the person completing the PDF IAD Report (and indicate you
submitted electronically and that you will maintain a signed copy);
Date
• Add the date that you affixed your signature to the document.
Signature (must be done prior to submission!)
• Paste in and size a copy of your signature from a PDF document and make it fit in this area
for signatures (sign a blank piece of paper, scan it back into your computer and save as a
PDF document; click on your signature (a box should form around it; & copy it, and past it
onto this page; move and size as needed to fit). You will need to significantly down-size it
so that when pasted in it fits. See next slide.
PDF IAD Reporting– Pg 5: Preparer’s Signature
PDF IAD Reporting– Pg 5: Preparer’s Signature - Example
Place new snipit here
PREPARER’S SIGNATURE cont. (Yours should look like this.)
Signature
• Following the instructions in last slide, paste in and size a copy of your signature from a
word document or PDF document and make it fit in this area for signatures (sign a blank
piece of paper, scan it back into your computer and save as a Word or PDF document;
highlight it, copy it, and past it onto this page, moving and sizing it to fit
Date
• Add the date that you affixed your signature to the document
PDF IAD Reporting– Pg 5: Emailing PDF IAD for Review
Options Buttons
Spell Check- Checks the spelling on all written above and allows correction (click on button,
then ‘Start’ and ‘Done’ when completed).
Save Form- Saves the PDF IAD and what is written on it thus far. Please use the date and
client’s initials in the label you assign the PDF IAD you save. Keep all PDF
IADs in one location, so they are easy to find, should editing be needed.
Email Form- NOTE: This button does not work on this page! Please follow this process: 1.
Use the Save Form button to save the PDF IAD you have completed thus far
Please submit to Clinical Director for completion of form.
Print Form- Allows you to print form with what was written (as the Preparer, do not print and
sign, then scan back in, as Clinical Director Review editing will be turned off;
just save and forward to your Clinical Director for their review and signature).
PDF IAD Reporting– Pg 5: Emailing PDF IAD for Review
•
•
DO NOT USE THIS ICON TO EMAIL EITHER, OR YOU WILL LOSE THE
CONTENT OF THE PDF IAD YOU JUST COMPLETED AND SAVE A BLANK
COPY.
• Use the process described under “Email Form” in the last frame (33).
If you use the ‘File: Save As’ option, you will save the form, but lose anything
typed in it; you must use the Save Form button after the signature line.
PDF IAD Reporting– Pg 6:
This is what the sixth page of the
PDF IAD looks like. This page
will be broken down into 5
areas:
1. CLINICAL DIRECTOR
REVIEW
2. Date Reported to the
RBHA
3. Name & Credentials;
Date; Signature
4. Options Buttons
5. RBHA REVIEW and
Options Buttons
PDF IAD Reporting– Pg 6: Clinical Director Review
CLINICAL DIRECTOR REVIEW
Review of Incident, Actions Taken and/or Recommended
•
•
•
Your Clinical Director or Designee will then review the incident, documentation, actions
taken and/or recommended and document those here.
Document Recommendation of actions the Provider Agency will take to address this
incident and to keep similar incidents from occurring in the future;
These Actions would include changes to Provider Agency policies or procedures; staff
training, or other performance improvement activities.
PDF IAD Reporting– Pg 6: Clinical Director Review
CLINICAL DIRECTOR REVIEW Cont.
Date Reported to the T/RBHA
•
This is where the date you emailed the PDF IAD to Mercy Maricopa Integrated Care
([email protected]) is entered. This date should be within 2 business days your finding
out about the incident or the incident occurring.
PDF IAD Reporting– Pg 6: Clinical Director Signature
Place new snipit here
CLINICAL DIRECTOR REVIEW cont.
Name & Credentials
•
Please include the name and credentials (Degree; position at the Provider Agency, AZ State
License type, etc.) of the person completing the PDF IAD Report.
Date
•
Add the date that the review was completed.
Signature
•
Paste in and size a copy of your signature from a word document or PDF document and
make it fit in this area for signatures (sign a blank piece of paper, scan it back into your
computer and save as a Word or PDF document; highlight & copy it, and past it onto this
page; move and size as needed to fit). See next slide.
PDF IAD Reporting– Pg 6: Clinical Director Signature
PDF IAD Reporting– Pg 6: Clinical Director Signature
Place new snipit here
CLINICAL DIRECTOR REVIEW cont. (Yours should look like this.)
Signature*
• Following the instructions in last slide to paste in and size a copy of your signature from a
word document or PDF document and make it fit in this area for signatures (sign a blank
piece of paper, scan it back into your computer and save as a Word or PDF document;
highlight it, copy it, and past it onto this page, moving and sizing it to fit;
• * - If you cannot figure this out, you will need to maintain a fully completed and signed
copy of the PDF IAD at your agency; please let us know and we will offer you Technical
Assistance as needed.
Date
• Add the date that you affixed your signature to the document
PDF IAD Reporting– Pg 6: Emailing PDF IAD to GRBHSQI
CLINICAL DIRECTOR REVIEW cont.
Options Buttons
Spell Check- Checks the spelling on all written above and gives options and allows correction
Save Form- This button does not work. Please save the form by going to “File” – and then
“Save As”. Make sure to save as a PDF. This will ensure that the content on the
form is saved.
Email Form- (This button should work on this page!) To facilitate submission of the fully
completed PDF IAD to MMIC QI, the Clinical Director or Designee must click
on the Email Form Button.
Print Form- Allows you to print the completed form with what was written.
Incomplete, incorrect, or inaccurate IAD Reports- what happens?
• The MMIC QM Department reviews every IAD submitted for completeness,
accuracy and timeliness; any IAD that is incomplete or inaccurate is returned
to the Provider Agency who submitted the report. Any returned report is
expected to be corrected and resubmitted within 1 business day of it being
returned (or 24 hours). This process will continue until the document is
accurate and filled out completely.
• Should MMIC QM see a trend regarding IAD submission from a Provider
Agency (inaccurate, incomplete, submissions beyond the 48 hour/2 business
day requirement) then Technical Assistance will be offered. Should the issue
continue, a Performance Improvement Plan will be requested and increased
monitoring/review of IADs prior to submission by the Provider Agency will
be expected as part of that.
PDF IAD Reporting– Pg 6: RBHA REVIEW
T/RBHA REVIEW
Referred for Quality of Care (QOC) Investigation (FOR RBHA USE ONLY)
•
•
Each IAD sent to MMIC is reviewed to see if it qualifies as a Quality of Care
Investigation.
Options Buttons- for use by MMIC only
PDF Incident/Accident/Death (IAD) Reporting
Quick Review of Steps to Follow:
1. Save a copy of the MMIC PDF IAD as a blank form and use this
form to write up all IAD Reports for MMIC member.
2. Complete the PDF IAD form Red boxes (at minimum); save and
forward to your Clinical Director or Designee for final review,
signature, and submission to MMIC;
3. Make any MMIC requested corrections/edits and return the form
within 1 business day of the request;