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center59690000State of Nebraska DHHS-Division of Developmental DisabilitiesQuarterly Provider Incident Report Template Implementation Date: 7/28/17Revised: 12/30/19DATE: To: DDD Central Office Therap via SCOMM to: First name: DHHSDDQuality Last name: MailboxQuarterly Incident Report for Provider: Provider A Reporting period: 3rd Quarter Start Date: 7/1/17 – Ending Date: 9/30/17 DATA COMPILATION: Graph/Sheet 1:Graph/Sheet 2:Graph/Sheet 3:**This sample includes mock data only not based on the graphs.PROVIDER AND PARTICIPANT DATA ANALYSIS AND ACTION PLANS TO ADDRESS INCIDENT REDUCTION OR SYSTEMIC PATTERNSDIRECTIONS: This section includes a detailed compilation and analysis of quarterly incident report data. Complete all sections needing additional analysis. NOTE: Alphabetical sections B-T needing no analysis, as described in the table for the event category, should be deleted and removed from your Provider Report.A. This quarter there were 180 High Notification Level General Event Reports (GERs), which involved 185 high level incidents and 120 participants. In comparison, there were 210 High Notification GERs the prior quarter. B. AWOL/Missing Person: *Include Additional Analysis if any items in the table below are checked:Analysis:Item:Check all reasons for the additional analysis:If checked, explain reason(s):1XThere were three or more incidents for the quarter.There were five incidents this quarter.2A participant had three or more incidents.3This quarter’s total exceeded the prior provider or participant total.4There were systemic issues.Fill in the shaded sections with the number of GER events to complete your analysis:0incidents involved missing persons, and5involved participants leaving supervision.Action Plan to address Incident Reduction or Systemic patterns:Please explain in detail the action plans that will be taken or have already been taken to address this category of incidents for the participant or provider, or list why additional action plans should not be implemented to address the analysis of the incidents: Four events were at one location; however, the events were with different participants and no systemic patterns were noted. No additional actions are needed. C. Assault incidents: *Include Additional Analysis if any items in the table below are checked:Analysis:Item:Check all reasons for the additional analysis:If checked, explain reason(s):1XThere were thirteen or more incidents for the quarter.28 assault incidents were reported this quarter.2A participant had six or more incidents.3This quarter’s total exceeded the prior provider or participant total.4There were systemic issues.Fill in the shaded sections with the number of GER events to complete your analysis:28consisted of peer-to-peer-related assaults. 0of the assault incidents involved participants aggressing toward employees who sought medical attention. Action Plan to address Incident Reduction or Systemic patterns:Explain, in detail, action plans that will be taken or have already been taken to address incidents for the participant or provider, or list why additional action plans should not be implemented to address the analysis of the incidents: Based on the GER guidelines, eleven of the events don’t appear to meet the definition of high notification. The GER guidelines will be reviewed with the staff and the reviewer to ensure GERs are assigned as outlined in the GER Manual. 8 were at one site; however, no systemic patterns were noted. D. Altercation Incidents: *Include additional analysis if any items in the table below are checked:Analysis:Item:Check all reasons for the additional analysis:If checked, explain reason(s):1XThere were three or more incidents for the quarter.12 altercation events were reported this quarter. 2A participant had two or more incidents.3This quarter’s total exceeded the prior provider or participant total.4There were systemic issues.Fill in the shaded sections with the number of GER events to complete your analysis:12consisted of peer-to-peer-related incidents0of the assault incidents involved altercations with someone other than another participant. Action Plan to address Incident Reduction or Systemic patterns:Explain, in detail, action plans that will be taken or have already been taken to address incidents for the participant or provider, or list why additional action plans should not be implemented to address the analysis of the incidents: 8 incidents happened at one location; however different participants were involved and no systemic concerns were notedE. Complaints and/or Possible Litigation Incidents: *Include additional analysis if any items in the table below are checked:Analysis:Item:Check all reasons for the additional analysis:If checked, explain reason(s):1XThere were incidents for the quarter.Five abuse/neglect events were reported this quarter.2There were systemic issues.Fill in the shaded sections with the number of GER events to complete your analysis:0of these reports were turned over to APS, and not investigated internally. This was due to N/A5complaints were investigated internally. 3were found to be unsubstantiated for abuse/neglect. 1were found to be substantiated abuse. 1were found to be substantiated neglect. 0were found to be substantiated exploitation. Appropriate personnel action, including One person moved to a different home. Two employees were terminated.was taken in all substantiated cases. 5were reported appropriately. 5were investigated properly.Action Plan to address Incident Reduction or Systemic patterns:Explain, in detail, action plans that will be taken or have already been taken to address incidents for the participant or provider, or list why additional action plans should not be implemented to address the analysis of the incidents: No actions are necessary since the employees were terminated and the participant moved. F. Deaths: *Include additional analysis if any items in the table below are checked:Analysis:Item:Check all reasons for the additional analysis:If checked, explain reason(s):1XThere were incidents for the quarter.3 deaths occurred this quarter.2There were systemic issues.Fill in the shaded sections with the number of GER events to complete your analysis:3deaths were investigated internally. 3deaths were reported to DHHS. 3deaths were investigated by DPH. 3deaths were reported appropriately. 0were found to be substantiated abuse. 0were found to be substantiated neglect. Action Plan to address Incident Reduction or Systemic patterns:Explain, in detail, action plans that will be taken or have already been taken to address incidents for the participant or provider, or list why additional action plans should not be implemented to address the analysis of the incidents: No patterns or systemic concerns were noted. No additional actions are needed. G. Emergency Safety Intervention Incidents: *Include Additional Analysis if any items in the table below are checked:Analysis:Item:Check all reasons for the additional analysis:If checked, explain reason(s):1XThere were incidents for the quarter.11 ESI events occurred this quarter.2There were systemic issues.Fill in the shaded sections with the number of GER events to complete your analysis:11of the interventions were approved. 0of the interventions were reported as abuse or neglect. 0injuries related to Emergency Safety Interventions occurred. 11of the interventions were part of a safety plan. 0of the interventions were unplanned and not part of a safety plan. Action Plan to address Incident Reduction or Systemic patterns:Explain, in detail, action plans that will be taken or have already been taken to address incidents for the participant or provider, or list why additional action plans should not be implemented to address the analysis of the incidents: One participant had five events. Another participant had four events. The safety plans were followed properly. Responsive actions, including medication changes and new intervention strategies, were put into place by the teams. No patterns or systemic concerns were noted.I. Hospital Incidents: *Include Additional Analysis if any items in the table below are checked:Analysis:Item:Check all reasons for the additional analysis:If checked, explain reason(s):1XThere were eleven or more incidents for the quarter.41 hospital events were processed this quarter.2XA participant had three or more incidents.Separately, two participants had three hospital events.3This quarter’s total exceeded the prior provider or participant total.4There were systemic issues.Fill in the shaded sections with the number of GER events to complete your analysis:0of the admission incidents were for mental health reasons. 41of the admission incidents were for physical health hospital admissions incidents. Action Plan to address Incident Reduction or Systemic patterns:Explain, in detail, action plans that will be taken or have already been taken to address incidents for the participant or provider, or list why additional action plans should not be implemented to address the analysis of the incidents: A request for additional funding has been submitted for one of the participants with three events. The other participant with three events has a chronic condition the team is addressing. No additional actions are needed since no systemic concerns are noted. J. Injuries: *Include additional analysis if any items in the table below are checked:Analysis:Item:Check all reasons for the additional analysis:If checked, explain reason(s):1XThere were sixteen or more incidents for the quarter.44 events were reported this quarter. 2XA participant had four or more incidents.Two participants had four incidents this quarter.3This quarter’s total exceeded the prior provider or participant total.4There were systemic issues.Fill in the shaded sections with the number of GER events to complete your analysis:30of these injuries required no treatment, 9of them were minor, requiring basic first aid, 2of them were moderate, requiring nurse or physician treatment. Finally, 3of the injuries were severe, requiring an emergency room visit, with or without admission. 0injuries were related to Emergency Safety Interventions, 20were of unknown origin, and 0injuries were due to displacement due to fires.0injuries required medical attention to staff persons and others resulting from the behavior of a participant.The leading causes of injuries were Due to unknown origin. Action Plan to address Incident Reduction or Systemic patterns:Explain, in detail, action plans that will be taken or have already been taken to address incidents for the participant or provider, or list why additional action plans should not be implemented to address the analysis of the incidents: No systemic trends were noted. The Safety plan was followed for the participant with five events and a psychiatric review is planned. Team actions, including adjustments to seizure medication and a medical appointment with the physicians, occurred. No additional actions are necessary. K. Falls with injuries: *Include Additional Analysis if any items in the table below are checked:Analysis:Item:Check all reasons for the additional analysis:If checked, explain reason(s):1XA participant had two or more incidents.3 participants had 2 or more fall events this quarter. 2This quarter’s total exceeded the prior provider or participant total.3There were systemic issues.Fill in the shaded sections with the number of GER events to complete your analysis:13Falls with injury occurred this quarter4required no treatment. 6of these injuries required minor first aid, 0were moderate, requiring nurse or physician treatment.3were severe, requiring hospital/ER treatment.Action Plan to address Incident Reduction or Systemic patterns:Explain, in detail, action plans that will be taken or have already been taken to address incidents for the participant or provider, or list why additional action plans should not be implemented to address the analysis of the incidents: No additional actions are needed since no systemic concerns were noted. Actions were taken, including medical appointments, for one participant with two falls; additional monitoring for one participant with two or more falls; and seizure medication adjustments were taken with the one participant with two or more falls with injuries.L. Law Enforcement Incidents: *Include additional analysis if any items in the table below are checked:Analysis:Item:Check all reasons for the additional analysis:If checked, explain reason(s):1XThere were incidents for the quarter.11 law enforcement events occurred this quarter. 2A participant had six or more incidents.3This quarter’s total exceeded the prior provider or participant total.4There were systemic issues.Fill in the shaded sections with the number of GER events to complete your analysis:11law enforcement events occurred this this quarter.11participants were involved with the law enforcement events this quarter.1law enforcement contact incidents were called in by the participant,8were called in by the provider, and 2were called by someone from the community. Action Plan to address Incident Reduction or Systemic patterns:Explain, in detail, action plans that will be taken or have already been taken to address incidents for the participant or provider, or list why additional action plans should not be implemented to address the analysis of the incidents: No additional actions are needed. No systemic concerns were noted as there were different participants involved with the eventsR. List any GER incidents not previously listed above. Include totals and any additional analysis. These need to be addressed in action plans since high notification was used for incidents not listed in the GER Instruction Guide Reportable Incident List.Analysis: Fill in the shaded sections with the number of GER events to complete your analysis:4incidents were reported in theBehavioralTherap category. (Repeat as needed) 8incidents were reported in theChange of ConditionTherap category. (Repeat as needed) Action Plan to address Incident Reduction or Systemic patterns:Explain, in detail, action plans that will be taken or have already been taken to address incidents for the participant or provider, or list why additional action plans should not be implemented to address the analysis of the incidents: The four behavioral events did not meet the high notification definition in the GER guidelines. The eight change of condition events did not meet the high notification definition. The staff will be trained on the GER manual to ensure they know what constitutes a high notification event. S. There were 3 participants with more than 4 high GERs.Analysis:Action Plan to address Incident Reduction or Systemic patterns:Explain, in detail, action plans that will be taken or have already been taken to address incidents for the participant or provider, or list why additional action plans should not be implemented to address the analysis of the incidents: One participant had 4 events, including 3 events in which he was the victim in assault events. One participant had eight events this quarter including three aggressor events with another participant. No additional actions are needed since for these two participants the team has implemented a support plan strategies. In addition, the participants now work in separate areas. One participant had six events. Additional team actions are needed to address the incidents for the participant. T. Participant trends included… The one participant with six events, noted in section S, was involved with assault events, an injury event of gasping for breath while eating an apple, and an abuse/neglect event. Analysis:Action Plan to address Incident Reduction or Systemic patterns:Explain, in detail, action plans that will be taken or have already been taken to address incidents for the participant or provider, or list why additional action plans should not be implemented to address the analysis of the incidents: A team meeting to review this participant’s plan is needed. DATA INTERPRETATION:DIRECTIONS: This section includes overall data interpretation, including reasons for the performance or reasons for the overall data increases/decreases. Include reasons why data points are/are not determined to be problematic.Address how GERs were entered, processed, and approved.Overall Incident Decrease is possibly due to Unknown reasons Additional actions to address the overall incident increase are/are not needed becausethe events decreased this quarter.Reporting of incidents to provider management, the participant, family member/legal representative (As appropriate), the Service Coordinator, CPS/APS and Law Enforcement as appropriate was completed properly and timely for 185 of 185 GER incidents.GERs were approved properly and timely, based on the Report Date and Approve Date Columns of the Excel GER Management Summary Report, for 185 of 185 GER incidents.Notification levels for GERs were initially completed properly for 173 of 185 GERs. GERs were completed, based on the event date and report date columns of the Excel GER Management Summary Report, within required timelines for 185 of 185 GER incidents.Corrective actions, based on the corrective action taken and plan of future action columns of the Excel GER Management Summary Report were taken for 185 of 185 GER incidents.Action Plan to address Incident Reduction or Systemic patterns:Explain, in detail, action plans that will be taken or have already been taken to address incidents for the participant or provider, or list why additional action plans should not be implemented to address the analysis of the incidents: As previously noted, staff will be trained on the implementation of the DDD GER Guideline manual. Sincerely,Name(s) and Title(s) of person Completing Report:Sally WinkelmannWhen finished, send a Word or PDF version of the Provider Report to: Therap via SCOMM to:? First name: DHHSDDQuality Last name: MailboxQuarter:Quarter Data:Quarterly Report Due Date:1st QuarterJanuary – MarchApril 30th2nd QuarterApril – JuneJuly 30th3rd QuarterJuly – SeptemberOctober 30th4th QuarterOctober - DecemberJanuary 30th ................
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