Medicaid Services Update

To:  All ADvantage Providers

Subject: Critical Incident Report Process

Date:  May 16, 2022

The ADvantage Program requires any serious incident that harms or potentially harms a Member’s health, safety or well-being to be immediately identified, reported, reviewed, investigated and appropriately addressed.  As required by state law, providers of ADvantage services must report abuse, neglect and/or exploitation (ANE) allegations to Adult Protective Services (APS).  In addition, the ADvantage provider that first identifies a serious incident is required to report the incident to the Medicaid Services Unit (MSU) via Harmony within one business day of knowledge of the incident.

Critical Incidents

The following critical incidents must be reported to the MSU:

• Sexual abuse*
• Physical abuse*
• Neglect*
• Exploitation*
• Medication error requiring medical attention
• Fall or injuries requiring medical attention
• Loss of residence due to disaster
• Suicide attempt or suicidal ideation
• Questionable (unexpected) death
• Interruption of critical medical supports
• Member lost or missing
• Use of restraints*
• Allegation related to the Personal Care Assistant (PCA) or Personal Service Assistant (PSA)

*Any of these critical incidents must be reported to APS which is the lead investigative authority for these incidents. The Oklahoma Human Services contact information for Adult Protective Services is www.abuseisnotok.org  or www.okhotline.org, or 1-800-522-3511.

ADv-Critical Incident Report

When an ADvantage provider becomes aware of a critical incident, the provider must notify the MSU within one business day.  The provider notifies MSU by completing the ADv-Critical Incident Report form (CIR) and submits it through Provider Question (PQ) in the secure Harmony portal, following the instruction provided in the job sheet linked below.  This process now allows for the assigned Case Manager to be notified of the Critical Incident at the same time notification is submitted to MSU. 

All communications regarding specific details related to Critical Incidents should be kept within the Critical Incident PQ ticket in Harmony due to Member privacy and should not take place within Notes in the Member Chapter in Harmony.  If a provider is unsure if a Critical Incident has been reported, they should report the incident as instructed.

Case Manager Internal Investigation and Investigative Report

The ADvantage Case Management Provider is responsible for completing their own internal investigation of critical incidents unless they have been directed from an authorized government entity, including MSU, APS, OCA or other authority not to do so.  The Case Management provider coordinates their internal critical incident investigation and response efforts with governmental investigative authorities as required by law.

The Case Manager follows up on the reported incident, as appropriate, and submits the ADv-Case Manager Investigative Report form within 10 business days after the initial CIR is completed.  The ADV-Case Manager Investigative Report form has been developed to help guide the case manager’s investigation, and to ensure the appropriate action is taken and information obtained.  Instructions for completing and submitting this form can be found in the job sheet linked below. 

MSU requests the Case Management Supervisor staff all Critical Incident Reports with the assigned Case Manager and review all open critical incidents at least monthly to ensure proper handling of incidents. 

MSU Escalated Issues team

The MSU Escalated Issues team (EI) reviews all critical incident reports and case manager investigative reports received to determine whether the appropriate response to each incident occurred.  The MSU uses the following criteria in determining whether a response is adequate for resolution of the critical incident:

• An adequate description of the incident has been obtained
• Documentation reflects the assessment of the illness or injury and its impact to the Member’s health and welfare
• Documentation reflects that appropriate action has been taken to assure the Member’s continued health and welfare
• Documented history of similar events for previous incidents in the past six months

The EI team will work with the Case Manager when necessary to identify barriers to service, prevent future incidents and assure continued Member health and welfare.  The Escalated Issues team may suggest resources and services available to Members when appropriate.  When communicating with an EI team member within Harmony, the provider should reply and append responses within the note added by MSU. 

The EI team will monitor for timely receipt of required information.  If the Case Manager Investigative Report has not been received after ten business days has passed from the time a CIR was submitted to MSU, the EI staff may reassign the Critical Incident PQ ticket to the Case Manager Supervisor for appropriate action.  The EI team member may reassign the ticket to the Case Manager Supervisor or agency CQI for appropriate action for other reasons or concerns when appropriate.   

Once EI has determined that the appropriate response has occurred, the EI team member will complete the Critical Incident PQ ticket and update the status to Complete or Investigation (MSU only).  These status types should not be used by, or changed by, the provider.    

The ADvantage Case Manager is responsible for the ongoing monitoring of the health and welfare of Members and providing the necessary education and intervention related to abuse, neglect, and exploitation of Members.  Case Managers should provide prevention and education to Members and their caregivers related to abuse, neglect, and exploitation annually at the Member’s yearly reassessment and addressed in Case Manager’s monthly monitoring contacts with the Member.

Non-critical incidents

Policy, 317:35-17-27 Incident Reporting, requires that both critical and non-critical incidents involving the health and welfare of ADvantage Waiver Members be reported to the Oklahoma Human Services Medicaid Services Unit (MSU).

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, but are not limited to, the following:

• Falls or other injuries that do not require medical attention
• Theft allegations
• Mental Anguish or Degradation
• Threatening or inappropriate behavior
• Substance abuse or use 
• Serious allegations related to a provider agency
  
• Law enforcement involvement due to challenging behaviors
• Health & Welfare Risk

If these non-critical incidents occur, the ADvantage provider that first identifies the incident is required to report the incident to the Medicaid Services Unit.  This is done by completing a Provider Question ticket in Harmony with the Inquiry Type of Potential Escalated Issue (Not Critical Incident).   The Escalated Issues team reviews these incidents and follows up with the Case Manager or others to ensure appropriate actions are taken to identify barriers to service, prevent future incidents and assure continued Member health and welfare when appropriate. 

Harmony Job Sheet

The Harmony Job Sheet referenced above can be found here: Job Sheets - Google Drive
If the link to the Job Sheet is not working, the Job Sheet can be found in the Harmony Library Site (Provider Staff).

*There is no change to the current State Plan Personal Care Critical Incident Process.

If you have any questions regarding the information provided above, please feel free to contact us via Harmony Provider Question.     

COMMUNITY LIVING, AGING AND PROTECTIVE SERVICES | MEDICAID SERVICES UNIT
ADvantage Administration | State Plan Care Unit | Medical Eligibility Services
Office: 918-933-4900 | CareLine: 800-435-4711