Incident Reporting
The types of events that are considered incidents
What is injuries, medical emergencies (including mental health emergencies), elopements, deaths, Emergency Use of Controlled Procedures (restraints), emergency calls (fire department), behavioral incidents (including physical aggression with injury, severe property destruction, etc.), emergency relocation, suspected or witnessed abuse/neglect.
The timeframe for which the Individual Abuse Prevention Plan (otherwise known as the Risk Assessment) is to be developed and reviewed by the individual and their team
What is no later than the date of admission into the program or start of services
The employee responsible for overseeing and monitoring the individual's care/status
The Designated Coordinator (Program Director), in conjunction with the Designated Manager (Area Director)
The maximum temperature that is considered 'safe' at the Community Residential Settings
What is 120 degrees or below
The treatment that is completed during a review of medication records
What is the Medication Administration Record review *This is to be completed monthly, looking at the previous month's medication administration record- specifically looking for any missed documentation, medication errors, out of stock notations, and outlining those particularly and the follow up (training, corrective action, or maltreatment report) that was done in response
The timeframe for which you need to notify the guardian (if applicable) and case manager
What is within 24 hours of the Company having knowledge of the incident
The timeframe for which the Program Abuse Prevention Plan needs to be reviewed by the individual and their team at the time of admission
What is no later than the date of admission into the program or start of services (documented on the Meeting Minutes as a 'Yes' that the Program Abuse Prevention Plan was reviewed)
The external (county) document that needs to be on file for each individual
The Support Plan (and signature page)
The document that the County licensor reviews at the time of the licensing visit (outlining the physical plant, individuals supported, etc.)
What is the Program Abuse Prevention Plan
The frequency for which financial accounts need to be reconciled if the Company is deemed responsible
What is monthly. *This means that the bank statements are present for each account, the bank statement and the registers reconcile, receipts are present, cash is accounted for, and any discrepancies reported to a supervisor and/or Quality Improvement.
The document that is utilized if the police are called due to a behavioral incident, crisis line is called for assistance, or PRN is used to manage behavior.
What is the BIRF (Behavior Intervention Report Form)
The timeframe for which consents that authorize financial management, medication management, release of information, information regarding service recipient rights, etc. need to be reviewed and completed by the individual and their team
What is no later than the date of admission into the program or start of services (documented on the Admission Meeting consent packet; Financial Consent form; Medical Authorization form; Service Recipient Rights form; Release of Information form, etc.).
The documents that make up the individual's Company Support Plan Addendum
The Support Plan Addendum document, Risk Assessment, ISSA, Positive Support Strategy Review, Health Needs Record, Meeting Minutes, Action Plan Summaries, Action Plans, Appointment tracker/medical documents (protocols), Medication Administration Records, Injection Agreements, Financial records
The frequency for fire drills to occur
What is at least quarterly (but Company practice is monthly); *with additional severe weather drills recommended twice per year
The frequency for which the individual's itemized financial reports need to be provided to the team
What is defined on the Financial Consent (admission) or on the Annual Support Plan Addendum document. *This is a licensing requirement, need to show proof of the itemized reports being provided at the frequency requested (monthly, quarterly, semi-annually, etc.)
The document or report that is utilized if maltreatment is suspected or witnessed
What is the MAARC (Minnesota Adult Abuse Reporting Center) form or submission on the website
What is no later than the date of admission into the program or start of services (documented on page 2 of the Admission Consent packet)
The document(s) that are 'living' documents for the individuals, which may change, depending on the condition of the individual?
What is the ISSA, Health Needs Record, Risk Assessment (main documents); although others may change (consents due to responsibility, protocols due to changes in medical care, etc.). **It is important to regularly review plans, check in with staff/PS, observe individual, and review medical referrals.
It's the document that the Company records water temperature checks, carbon monoxide/smoke detector checks, fire/severe weather drills, maintenance concerns, etc.
What is the QARF (Quality Assurance Report Form) *Completed monthly and filed in the Licensing binder at the site
The document that is utilized by the individual's prescriber that outlines when to report if there are refused or missed dosages.
What is the Prescriber Directive. *This is important to have on file for any individual that has a history of medication refusals or start to refuse medications. It outlines the threshold for when to report (example: prescriber indicates to notify if 3 consecutive dosages of Risperdal is missed).
The action to take if a staff is suspected of maltreatment
What is suspension (or immediate consultation with your supervisor if there are extenuating circumstances)
The timeframe for which the staff need to be trained on the individual's plan of care upon admission.
What is during their first shift working with the individual, if not possible prior to admission. **The statute does indicate that the Risk Assessment can be reviewed within 72 hours of the first contact.
The consequences of not revising plans to reflect individual's current status
The individual is potentially harmed, the staff don't understand direction, a maltreatment report is filed, the Company receives negative licensing action.
The actions to take if an individual does not allow staff into their bedroom and their are cleanliness concerns
What is consulting with your supervisor, Quality Improvement staff. **It is the Company's responsibility to provide a safe and hazard free living environment for all individuals, regardless of the individual's preferences.
The platforms for which the individual's documents should be stored
What is the individual's iServe record AND the individual's Shared folder. **In particular the individual's consents, county Support plan, medical referrals on appointment tracker, etc.