Unusual incidents, sentinel events and reporting requirements
Date: May 18, 2018
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Does your facility have a Compliance Director? If not, does your leadership know about Unusual Incident Reporting Requirements? The Department of Health Care Services (DHCS) refers to this as an UNUSUAL INCIDENT/INJURY/DEATH REPORT, while the Joint Commission (JCAHO) calls them Sentinel Events. There are many scenarios that require a formal report to your supervising agencies. And not reporting them can lead to serious problems for your facility. I believe the term “CYA” was created specifically for addiction treatment facilities.

Here’s an example:
Andy Addict was on a beach day outing with ABC Treatment Center. Andy cut his foot on the rocks and was advised by Mr. Program Director that it would be fine, no medical treatment was necessary. No note was made in Andy’s EMR either. (PD probably was busy…agghh) Andy completes treatment that week and returns home out of state. He develops a staff infection, get four toes amputated, and sues ABC. With no documentation or report ABC loses a huge settlement and has their reputation ruined. Certainly, at the time, Mr. Program Director didn’t think for a second that a minor cut would lead to this. But this is exactly why there are standards, policies, and procedures that MUST be adhered to.

Into Action Consulting, Inc. can be your compliance management team! Our expertise and experience will be used to train your staff on how to proactively prepare for situations, what to do when there is an event that is reportable and how to handle communication between your facility and supervising agencies.

We have developed a method of training your staff that will bring a level of confidence to the entire organization; online training management software, in-service didactic lectures, mock scenario training and certificates in emergency preparedness.

The standards and policies below are for California specifically, so make sure you check with your state if you plan on implementing what is provided here. We have included this to help you ensure you are aware of the standards and regulations.

10561 (b) (c) Title 9 Regulations & AOD Certification Standards
The Facility shall make a telephonic report to the Department of Health Care Services Complaints and Counselor Certification Division at (916) 322-2911 within one (1) working day for any of the following events:

  1. Death of any resident from any cause – even if death did not occur at facility.
  2. Any facility related injury of any resident which requires medical treatment.
  3. All cases of communicable disease reportable under Section 3125 of the Health and Safety Code or Section 2500, 2502, or 2503 of Title 17, California Administrative Code shall be reported to the local health officer in addition to the CDC.
  4. Poisonings.
  5. Natural disaster.
  6. Fires or explosions which occur in or on the premises.

The telephonic report is to be followed by a written report to the Department within seven (7) days of the event. Unusual Incident or Injury reports must be submitted to your Licensing Analyst. Death Reports must be submitted by fax/email to the Complaints and Counselor Certification Division at (916) 440-5094.

Policy If any of the above mentioned should occur, the staff member(s) present top priority is the safety of staff and/or client. After the situation has been deemed as safe, the staff present shall notify immediate supervisor of event. This supervisor will ask observing staff to write a summary of the event and forward it directly to the Compliance Director. The Compliance Director will then review summary, interview pertinent staff/client(s), and make a telephonic report to facility analyst within one working day. Compliance Director will then prepare a written, detailed report within seven (7) days of telephonic report.

Organizational Facility Changes
The Compliance director will notify the analyst for this facility of any of the following changes within ten (10) working days in writing via email or fax:

  1. Organization changes as specified in section 10531 (a)
  2. Change in mailing address
  3. Change in administrator. Including name, address, and qualifications.
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