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7.4.1
Introduction
Significant events, such as accidents, injuries, allegations of
abuse, human rights violations, and deaths require careful examination
and review to ensure the protection of behavioral health recipients.
ADHS/DBHS, as well as other federal and state agencies, requires
the prompt reporting of significant events involving persons receiving
services within the public behavioral health system. The reporting
of significant events to Arizona Department of Health Services/Division
of Behavioral Health Services (ADHS/DBHS), such as incidents, accidents,
and deaths, serves the following purposes:
- The collection
of relevant information facilitates a comprehensive review and
investigation when indicated;
- Compliance
with notification requirements to the Centers for Medicare and
Medicaid Services (CMS), Arizona Health Care Cost Containment
System (AHCCCS), the Arizona Center for Disability Law, and ADHS/Office
of Behavioral Health Licensure (OBHL) as applicable; and
- The trending
and analysis of significant events can identify opportunities
for behavioral health system improvements.
The intent of
this section is to identify reporting requirements for behavioral
health providers following an incident, accident, or death involving
a behavioral health recipient. In addition, T/RBHAs may require
subcontracted providers to submit a written summary of their
review of deaths of adult Non-Seriously Mentally Ill (SMI) behavioral health recipients. Behavioral health providers must
be aware of what constitutes an event that requires reporting (by
either the T/RBHA or behavioral health providers) to:
- CMS;
- AHCCCS;
- ADHS/DBHS;
- The Arizona
Center for Disability Law;
- ADHS/OBHL.
Behavioral health providers must know what information is to be reported, including any applicable forms
and/or reports; and where the requisite information must be sent within the agencies identified above.
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7.4.2
References
The following citations can serve as additional resources for this
content area:
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7.4.3
Scope
To whom does this apply?
All persons
receiving behavioral health services.
7.4.4
Did you know…?
- All
deaths, regardless of whether the enrolled recipient is a child,
adult with Serious Mental Illness or adult without a Serious
Mental Illness, are reviewed by ADHS/DBHS Medical Director or
designee, and selected cases are referred to the ADHS/DBHS
Mortality and Morbidity Committee for further review and potential
action, in accordance with ADHS/DBHS established quality
assurance process.
- OBHL licensed Level I behavioral
health facilities are required to report any serious occurrence that occurs as a result
of a seclusion and restraint event, in accordance with
Section 7.3, Seclusion and
Restraint Reporting.
- Upon recognition
of abuse, neglect or exploitation of an incapacitated person, behavioral health providers
must immediately report the allegation to the appropriate authorities
(i.e., police or protective services worker) in accordance with
A.R.S. § 46-454. The oral report
must be followed up by a written report within 48 hours. See
Section 7.6, Duty to Report Abuse, Neglect or Exploitation.
- Each state
has a designated protection and advocacy system. In Arizona, the
Arizona Center for Disability Law serves as the designated protection
and advocacy agency.
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7.4.5
Definitions
Abuse
Behavioral Health
Recipient
Enrolled Person
Exploitation
Incapacity
Incident
or Accident
Level
I Facility
Neglect
Prevention Activity
Serious
Injury
Serious
Occurrence
7.4.6
Objectives
To identify reporting requirements for behavioral health
providers following:
- An
incident, accident or death of any behavioral health recipient;
- An
incident, accident, or death of any behavioral health recipient
during a prevention activity, regardless of his or her enrollment
status; and
- An allegation
of abuse of any behavioral health recipient determined have a Serious Mental Illness.
To identify procedures for behavioral
health providers in submitting a summary of their review of deaths
of adult Non-SMI behavioral health recipients.
7.4.7
Procedures
7.4.7-A.
Reporting incidents, accidents, and deaths to the T/RBHA
Behavioral health providers must report any incident or
accident as defined by this section of an enrolled behavioral health recipient to the T/RBHA within 48 hours.
Behavioral health
providers are to report any incidents or accidents involving a Gila
River RBHA enrolled member to the Gila River RBHA Manager of Quality
Management/Utilization Management. Reports may be faxed to (520) 550-6040 or mailed to the following:
Gila River RBHA/New
Beginnings Building
ATT: Manager of QM/UM
Hu Hu Kam Memorial Hospital
P.O. Box 38
Sacaton, AZ 85147
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7.4.7-B. Reporting incidents, accidents, and deaths during
prevention activities
Behavioral health providers are required
to report to the T/RBHA any incident, accident or death of a
behavioral health recipient participating in the T/RBHA or
provider sponsored prevention activity, as defined in this section,
regardless of his or her enrollment status with the T/RBHA within 48 hours.
PM Form 7.4.1,
Incident/Accident/Death Report Form
must be used for reporting incidents, accidents and
deaths of enrolled behavioral health recipients; and incidents, accidents and deaths occurring during prevention activities.
Reports may be
faxed to (520) 550-6040 or mailed to the following:
Gila River
RBHA/New Beginnings Building
ATT: Manager of QM/UM
Hu Hu Kam Memorial Hospital
P.O. Box 38
Sacaton, AZ 85147
7.4.7-C. Review of Deaths to the T/RBHA
T/RBHAs
may require behavioral health providers prepare and submit a written
summary of their review of deaths only for adult, Non-SMI behavioral
health recipients using the ADHS/DBHS Mortality Review Form,
contained in the Performance Improvement Specification Manual Section XVII. If Gila River RBHA makes such a request, the behavioral health
provider shall submit the completed information within thirty (30)
calendar days of the request.
7.4.7-D.
Reporting allegations of abuse towards persons determined to have
a Serious Mental Illness
Allegations of abuse concerning persons determined to have a Serious
Mental Illness must be reported within 48 hours to the T/RBHA.
PM
Form 7.4.1 Incident/Accident/Deaths Report Form must
be used to report occurrences of abuse to the T/RBHA.
Behavioral health
providers are to report allegations of abuse towards persons determined
to have a serious mental illness to the Gila River RBHA Manager
of Quality Management/Utilization Management. Reports may be faxed
to (520) 550-6040 or mailed to the following:
Gila River RBHA/New
Beginnings Building
ATT: Manager of QM/UM
Hu Hu Kam Memorial Hospital
P.O. Box 38
Sacaton, AZ 85147
7.4.7-E.
Reporting incidents, accidents and deaths to the Office of Behavioral Health Licensure
- Behavioral
health providers licensed by OBHL must provide notification to
OBHL involving any incident or accident as defined on
PM
Form 7.4.1.
Behavioral health
providers must orally report the above referenced events to ADHS/OBHL
within one working day of knowledge of the event (contact OBHL at
602-364-2595). The oral report must be followed up with a written incident
report within 5 working days. Behavioral health providers must maintain
a copy of the written incident report on the premises or at the
administrative office for at least 12 months after the date of the
written incident report.
Community Service Agencies (CSAs) which are not licensed with OBHL, are not
required to report any incidents, accidents or deaths to ADHS/OBHL
that occur during a T/RBHA or provider sponsored prevention
activity.
7.4.7-F. Reporting
deaths and serious occurrences in OBHL Level I Facilities
This subsection is applicable to Title XIX certified/OBHL
licensed Level I behavioral health facilities that provide inpatient
psychiatric services to persons under the age of 21.
Reporting
serious occurrences of behavioral health recipients:
Title XIX certified/OBHL licensed Level I behavioral health facilities
that provide inpatient psychiatric services to persons under the
age of 21 are required to report any serious occurrences (see definition)
involving a behavioral health recipient to:
- AHCCCS;
- The Arizona
Center for Disability Law; and
- CMS Regional
Office (for deaths only).
What are
the timeframes?
Any serious occurrence involving a behavioral health recipient in
a Level I facility must be reported to AHCCCS, the Arizona Center
for Disability Law, and the CMS Regional Office (for deaths only)
no later than close of business of the next business day following
the serious occurrence.
Where must
the report be sent?
For serious occurrence reporting, send information to:
- AHCCCS
FAX Number (602) 417-4855-Attention DHCM Behavioral Health
Administrator
- The Arizona
Center for Disability Law
FAX Number (602) 274-6779-Attention Investigator
- CMS Regional
Office (to report a death only)
FAX Number (415) 744-2692-Attention Survey & Certification
Coordinator
Other considerations
Specific documentation requirements apply to ADHS/OBHL licensed
behavioral health provider records. Please see
Section
4.2, Behavioral Health Medical Record Standards.
In the case
of a minor (person under the age of 18), the Level I facility must
also notify the person’s parent(s) or legal guardian(s) as
soon as possible, but no later than 24 hours from the serious occurrence.
Note that these
reporting requirements pertain only to serious occurrences (see
definition). Reports of non-serious occurrences and other events
must not be made to AHCCCS, the Arizona Center for Disability Law,
or CMS.
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7.4
Reporting of Incidents, Accidents and Deaths
Last Revised: 1/15/2010
Effective Date: 1/15/2010
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