3.06 – Incident Reporting Procedures
The purpose of the Open Door Incident Report is to document any unusual incident concerning any individual served and/or Open Door property in accordance with federal, state, and local regulations. Incident reports are utilized to ensure that preventative measures are initiated, that follow up measures are completed, and to allow for review of patterns and trends. Open Door views the incident report, as a way to improve quality of service and prevent or reduce likelihood of recurrence. There are two different classifications for incidents per regulations:
Unusual Incident (Ul)
An event or occurrence involving an individual that is not consistent with routine operations, policies and procedures, or the individual’s care or individual service plan, but is not a Major Unusual Incident. Unusual incidents includes, but not limited to, dental injuries; falls; injuries that are not significant injury per definition; medication errors without likely risk to health and welfare; overnight relocation of individual due to fire, natural disaster, or mechanical failure; an incident involving two individuals served that is not peer to-peer MUI per definition; rights code violations or unapproved behavior supports without a likely risk to health and welfare; emergency room or urgent care treatment center visits; and program implementation incidents.
Program Implementation Incidents: a UI involving failure to carry out a person-centered plan which such failure causes minimal risk or no risk. Examples include, but are not limited to, failing to provide supervision for short periods of time, automobile accidents without harm, and self-reported incidents with minimal risk.
Major Unusual Incident (MUI)
The alleged, suspected, or actual occurrence of an incident described in OAC 5123:17-02 (C)(16)(a), (C)(16)(b), or (C)(16)(c), when there is reason to believe the incident occurred. There are three administrative investigation procedures for Appendix A, B, and C categories of MUI as outlined in OAC 5123:17-02.
Initial Reporting Procedure
All Open Door employees are considered mandated reporters meaning they are required to complete the incident report and follow the reporting procedures outlined in Open Door policy. All incidents that require an incident report as defined above, should be written immediately (as soon as possible following incident) to ensure that further reporting requirements are met as listed in specific MUI categories. The Incident Report must be completed online through the employee hub Incident Report form.
In addition, the Open Door Incident Hotline Cell Phone (614-701-6993) must be notified for any incident requiring an incident report as soon as possible after incident. (Incidents that are not reported in a timely manner are subject to employee corrective action per policy 2.15-Employee Standards.) All Open Door employees must also notify the designated nurse for any medical related incident. Staff should document the name of personnel who answered the Incident Hotline and the nurses name, if applicable, on the Incident Report.
If the Incident Hotline does not answer, leave your name, phone number where you can be reached, along with a brief description of incident. You may also test the hotline. If no return call is received by the Incident Hotline on-call within 30 minutes, the individual completing the report must contact the Executive Director (614-563-2741) to report the incident.
Administrative Notifications/Immediate Actions
The Incident Hotline on-call personnel is responsible for ensuring that County MUI department is notified and that the incident report is submitted to County MUI per deadlines/reporting requirements specified in MUI RULE found in OAC 5123:17-02. Additionally, the Incident Hotline on-call must provide guardian notification within 24 hours of any incident. The Incident staff will document the contact to guardians on report.
The Incident Hotline on-call will be responsible for providing immediate action which ensures protection for health and welfare of the individual(s). This will include, but not limited to, removing staff from the schedule (if needed) noting the time that staff were removed from schedule, collecting statements, submitting referrals to OT, medical assessments, Speech, Psych or PT, recommending extra coverage, writing maintenance work orders, etc.
The Incident Hotline On-call will submit a record of incident to the Open Door team daily containing summary of incidents so that the responsible team can complete additional follow-up actions. The Chief Executive Director must also be contacted by Incident Hotline as soon as possible after incident not to exceed 24 hours after the incident for all MUIs.
Employee Removed from Schedule for Investigation
An employee may be removed from the direct contact with individuals an allegation of physical and sexual abuse and will not permitted to work until investigation is completed. This time will be unpaid until the investigation is completed. If a policy violation is substantiated, this time will be unpaid leave. If the investigation results in un-substantiation and no policy violation, the employee will be paid for the time missed for the investigation period (paid up to 40 hours – no overtime will be paid for unworked time).
Cooperation with Investigation
All Open Door employees are required to cooperate with investigations. This includes, but is not limited to, providing legible, detailed statements, participating in interviews, producing documentation, and responding to contacts from Open Door, MUI department, law enforcement, and other investigative entities timely. Failure to cooperate in investigations, may result in corrective action per policy 2.15-Employee Standards. Open Door is required to supply all information requested by County or State officials involved in investigations, including but limited to, staff name, contacts, social security numbers, Date of birth, etc.
After receiving the initial report, the Risk Management department will initiate UI/MUI follow up form. The Risk Management Department is responsible for inputting the immediate action, cause and contributing factors, and reporting requirements into Laserfiche system. Any pictures, supporting documentation will also be attached to incident follow-up.
The investigative action taken may vary according to the specific circumstances of each incident. Generally, the QIDP/Case Manager for designated service area is responsible for implementing the follow-up actions and preventative measures on incidents. This involves team discussion on person centered plan, referrals for ancillary services, medical follow up, etc.
Procedure for ICF conducting an investigation for Unknown Injuries:
All injuries of unknown origin will be investigated by the Risk Management Department.
- Statements will be obtained by all apartment staff in the previous 24 hours through electronic statement form. These statements will be attached to the Incident Form in Laserfiche system.
- A Photo of the injury will also be attached to the Incident Form in Laserfiche system.
- The Risk Management Department will complete their investigation process of all injuries of unknown origin within 5 working days.
- Unknown Injuries Review will be held within 5 working days to discuss the injury of unknown origin, cause and contributing factors and a prevention plan. This will be reviewed weekly during the UI review with all program team.
- An investigative follow-up report will be attached to the Incident form.
- The Risk Management Department will input the incident and follow up into Laserfiche.
Procedure for conducting an investigation for Uls
- The Risk Management Dept or Designee will take the initial call.
- Immediate action will be implemented by the designee to ensure the health and welfare of the individuals. The designee will complete all the preliminary investigation which could include collecting and copying documentation, interviewing individuals, remove the Primary Person Involved (PPI) from schedule (if abuse allegation), take pictures and make all of the appropriate phone calls and contacts.
- The Risk Management Department will conduct the formal investigation. Cause and Contributing factors will be identified.
- The Risk Management Department will recommend a prevention Plan. The QIDP and/or Team will review the prevention plan and execute for the health and welfare of the individuals.
- The investigation needs to be completed within 5 business days of incident. If incident is considered a health and welfare issue, Systems, Rights, and Review will be reviewed in weekly program meeting. If more information is needed, an attendance sheet will be collected and incident can be tabled until more information can be obtained.
Procedure for conducting an investigation for MUIs
The ICF will follow the MUI rule for compliance as well as the following:
- The Risk Management Department Designee takes the initial call.
- The Designee will complete all the preliminary investigation which could include collecting and copying documentation, interviewing residents and staff, removing the PPI from the schedule, take pictures and make all of the appropriate phone calls (including the County MUI Department, guardian, Chief Executive Director and Risk Management Coordinator immediately) as well as other contacts.
- The Risk Management Department will collaborate with the MUI unit for investigation process.
- The Risk Management Department will be the liaison between the County MUI Dept and the ICF .
- The ICF will complete an investigation within five days of the incident. The county MUI Dept will coordinate a time with Risk Management Department to come to the ICF to conduct an investigation. (The MUI Dept can turn over the investigation to the Risk Management Department and accept the findings of such along with recommendations at their discretion) and signed by Director.
- Incident needs to be addressed in 5 business days of incident. If MUI cannot coordinate a time within the 5-day requirement, the ICF will move forward to conduct the investigation. If more information is needed, an attendance sheet will be collected and incident can be tabled until more information can be obtained.
- The Risk Management Department will review the MUI at the Systems, Rights, and Review at weekly Program Meeting as well as review the Root Cause
Analysis, when applicable.
- Risk Management Department will provide the prevention plan to the QIDPs for implementation of any revisions of Person-Centered Plan, referrals for follow up, or for modifications to Open Door policies/procedures. All other recommendations will be forwarded to the appropriate staff for implementation.
- The Risk Management Department oversee to ensure that the supervisor has issued appropriate corrective actions and/or training to staff per investigation findings.
- The Risk Management Department and team are responsible to ensure that all recommendations are implemented including receiving evidence that external day service and transportation providers have completed necessary follow-up.
- The Risk Management Department will provide the investigative report to the MUI unit.
Waiver Procedures for conducting an investigation for MUIs (Picked up by County)
All Waiver services will follow the MUI rule for compliance as well as the following:
- The Incident Hotline takes the initial report.
- The Incident Hotline will contact the Executive Director.
- The Incident Hotline will remove the PPI from the schedule (if allegation of abuse), contact the County MUI unit, guardian, Administrator, and all other contacts.
- The Risk Management Department will collaborate with the MUI unit for investigation process. This will involve setting up appointments, collecting information for the MUI unit, etc.
- The Risk Management Department will be the liaison between the County MUI Department and Waiver provider.
- The MUI unit will provide a written summary of the investigation that includes whether the case was substantiated or unsubstantiated, preventative measures implemented in response to the major unusual incident.
- The Risk Management Department will forward recommendations to the appropriate staff for implementation.
- The Risk Management Department and Open Door team is responsible to ensure implementation of all recommendations including receiving evidence that day programs and transportation providers have implemented the measures necessary to protect individual.
When other issues are discovered during an investigation
During the course of an investigation, if another allegation is made aware, or if an unknown injury has been discovered, a separate investigation will take place that includes all previous 24-hour staff and workshop to address the allegation/unknown injury as well.
This investigation will include statements from staff and individuals involved and any other pertinent information needed to complete the investigation. For an unknown inj ury, the unknown injury investigation will be completed per above.
Administrative Report Completion and Review Procedure
The Risk Management Coordinator is responsible to complete the investigative report and compile all supporting documents for prevention plan, cause and contributing factors, nurses notes, action steps for follow-up, and any other pertinent related documents which will be attached to the incident report within 5 days of the incident. Any outstanding follow up recommendations/actions will be emailed on task grid for designated team members to complete. The Chief Executive Director will ensure that the necessary action is taken and that the follow up was assigned, as appropriate, and will review the On-Call Log daily, via email. The Executive Director may request further follow-up by noting on the investigative reports during review.
Weekly patterns/trends of incidents and any outstanding follow-up needs will be reviewed at the System Rights Safety review at Program meetings weekly.
A log of all Uls will be reviewed monthly in the UI meeting for each division. The review will consist of identifying patterns/trends, cause and contributing factors, and preventative measures. These meeting documents will be maintained in file in Risk Management department office. The task grid for follow-up will be emailed to team weekly.
The County MUI units review samplings of UI logs for agency providers to ensure patterns/trends are being identified and addressed. This log is made available to County MUI departments at their request for time period requested. The log shall include cause and contributing factors, prevention plans, follow-up actions,
Additionally, an annual analysis of all UIs and MUIs will be completed for all service areas. The Annual MUI/UI report will be emailed to the County MUI designee prior to deadlines outlined in 5123:17-02.
Last Revised: 5/20/22