OHCA Policies and Rules

317:35-17-27. Incident reporting

[Issued 09-12-22]

(a) Reporting requirement. Certified ADvantage provider staff should report critical and non-critical incidents involving the health and welfare of ADvantage Waiver members to the Oklahoma Human Services Medicaid Services Unit (MSU).

(b) Critical incidents. Critical incidents are events with potential to cause significant risk or serious harm to an ADvantage member's safety or well-being. Critical Incidents Reports (CIR) are completed for:

(1) Suspected maltreatment including abuse, neglect, or exploitation, per Section 10-103 of Title 43A of the Oklahoma Statutes (43A O.S. ' 10-103);

(2) Attempted suicide or suicidal ideation exhibition;

(3) Unexpected or questionable death;

(4) Falls or injuries requiring medical attention;

(5) Residence loss due to disaster;

(6) An interruption of needed medical supports;

(7) Lost or missing members;

(8) A medication error requiring medical attention;

(9) Use of physical restraints; or

(10) Allegations related to Personal Care Assistant (PCA) or Personal Service Assistant (PSA).

(c) Non-critical incidents. Non-critical incidents are events with potential to cause risk to an ADvantage member's safety and well-being, but do not rise to the critical incident level. Non-critical incidents include:

(1) Falls or injuries that do not require medical attention;

(2) Theft allegations;

(3) Threatening or inappropriate behavior;

(4) Substance abuse or use;

(5) Serious allegations related to a provider agency; and

(6) Law enforcement involvement due to challenging behaviors.

(d) Incident notification requirements. The reporting provider documents and submits to MSU incidents included in (b) and (c) of this Section in the electronic system on the CIR document, within one business day of becoming aware of the incident. The reporting provider notifies other persons or entities as required by law or regulation, including:

(1) When a service recipient dies, per OAC 340:100-3-35; and

(2) Investigative authorities immediately in cases of suspected maltreatment, as applicable, including:

(A) Local law enforcement;

(B) The Office of Client Advocacy when the alleged perpetrator is a community service worker, per OAC 340:2-3-33; and

(e) Internal Investigation. The provider completes an internal investigation of all critical incidents, unless directed otherwise by an authorized government entity.

(1) All provider investigative reports are submitted to the MSU within ten (10) working days after the initial CIR is completed.

(2) The provider coordinates internal critical incident investigation and response efforts with governmental investigative authorities as required by law.

(3) Provider supervisory staff run a monthly report from the electronic system to review all critical incidents submitted to the MSU. Doing so ensures proper handling and dispensation occurs, as required by the Centers for Medicare and Medicaid Services.

(f) Escalated issues. The Escalated Issues (EI) team reviews all CIR and determines whether the appropriate response occurred. EI coordinates their investigation and response efforts with governmental investigative authorities as required by law. For non-critical incident reports, EI reviews and works with the member, the member's informal support, provider, and others to verify appropriate actions are taken to identify barriers to service, prevent future incidents, and assure continued member health and welfare. Investigation results are communicated to the member, legal guardian, or next of kin as appropriate.

(g) Members and their representatives. Upon entry into the program and at least annually, each member is provided with resources and contact information to self-report complaints, abuse, neglect, exploitation, or other issues.

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.