Reporting Critical Incidents
At the end of this module, you will be able to determine when a critical incident has occurred, – who is responsible to report a critical incident, – when a critical incident situation needs to involve Protective Services, – and how to report it all.
To develop a critical incident management policy as part of the quality management system for the services delivered by An Answered Prayer, LLC and enhance its effort to obtain OLTL waiver approvals and meet regulatory compliance.
This is a general policy for critical incident reporting. It is mandatory that Administrators and Employees of An Answered Prayer, LLC- in-home care agency report incidents related to individuals who receive home and community-based services and supports in or from this agency or registry.
Terminologies: In interpreting this policy, the OLTL bulletin explains that it is important to Distinguish between Complaint and Incidents:
“Dissatisfaction with any aspect of program operations, activities, or services received or not received involving Home and Community-Based Services are considered complaints. All complaints should be directed to a participant’s Service Coordinator, Care Manager or the supervisor of this employee. When issues are not able to be resolved or a participant is not comfortable discussing with their Service Coordinator, Care Manager, or supervisor, the OLTL Quality Assurance Helpline is available at 1 (800) 757-5042. Concerns or complaints about services should not be reported as incidents.”
In the course of the provision of home and community-based services, an incident related to the following is considered reportable. An Answered Prayer adheres to the mandatory reporting of the following incidents:
Death, Injury, or Hospitalization – any incident that occurred as a result of the provision of Home and Community- Based Services or lack of provision of documented services.
Provider and Staff Misconduct – deliberate, willful, unlawful or dishonest activities related to the provision of Home and Community- Based Services.
Abuse – the infliction of injury, unreasonable confinement, intimidation, punishment, mental anguish, sexual abuse or exploitation on a participant.
Provider Reporting Requirements
Home care agencies are required to report all critical incidents involving CHC participants to the Managed Care Organization (MCO) within 24 hours of discovery, and after ensuring the health and safety of the participant. For all incidents that meet the state’s criteria for critical incidents, Long-term services and supports (LTSS) Providers must report the incidents in the state’s Enterprise Incident Management (EIM) system within 48 hours. All investigations and followup activities must be completed and documented in EIM within 30 days.
long-term services and supports (LTSS) Provider Executive Directors or CEOs of the agency need to assign one employee to become the Business Partner (BP) Administrator for the state’s Enterprise Incident Management (EIM) system, and one secondary BP Admin. This designated BP Admin will be responsible for assigning EIM userIDs to other employees who will be filing critical incidents to the state.
Critical Incident Categories
Death (other than by natural causes)
• Serious injury that results in emergency room visits, hospitalizations, or death.
• Hospitalization except in certain cases, such as hospital stays that were planned in advance
• Provider or staff misconduct, including deliberate, willful, unlawful, or dishonest activities
• Abuse, which includes the infliction of injury, unreasonable confinement, intimidation, punishment, mental anguish, or sexual abuse of a participant. Types of abuse include, but are not necessarily limited to:
Physical abuse, defined as a physical act by an individual that may cause physical injury to a participant
Psychological abuse, defined as an act, other than verbal, that may inflict emotional harm, invoke fear, or humiliate,
intimidate, degrade or demean a participant;
Sexual abuse, defined as an act or attempted act, such as rape, incest, sexual molestation, sexual exploitation, or sexual harassment and/ or inappropriate or unwanted touching of a participant;
Verbal abuse, defined as using words to threaten, coerce, intimidate, degrade, demean, harass, or humiliate a participant. 1. Neglect, which includes the failure to provide a participant the reasonable care that he or she requires, including but not limited to food, clothing, shelter, medical care, personal hygiene, and protection from harm. Types of neglect include: Seclusion, which is the involuntary confinement of an individual alone in a room or an area from which the individual is physically prevented from having contact with others or leaving; and -Abandonment, which is the desertion by anyone who assumed caregiving responsibilities for a UPMC CHC participant. • Exploitation, which is an act of depriving, defrauding, or otherwise obtaining the personal property from a participant in an unjust, or cruel manner, against one’s will, or without one’s consent, or knowledge for the benefit of self or others; • Restraint, which includes any physical, chemical or mechanical intervention that is used to control acute, episodic behavior that restricts the movement or function of the individual or a portion of the individual’s body. Use of restraints and seclusion are both restrictive interventions, which are actions or procedures that limit an individual’s movement, a person’s access to other individuals, locations or activities, or restricts participant rights;
• Service interruption, which includes any event that results in the participant’s inability to receive services that places his or her health and or safety at risk. This includes involuntary termination by the provider agency, and failure of the participant’s back-up plan. If these events occur, the provider agency must have a plan for temporary stabilization; and • Medication errors that result in hospitalization, an emergency room visit or other medical intervention. • Any Preventable Serious Adverse Event (PSAE) discovered in a nursing facility must be reported in compliance with PA Bulletin 03-14-08 issued 09/13/2014. The facility must also notify the MCO on the claim and email email@example.com. First Steps Any provider, service coordinator, subcontractor, or UPMC employee who observes or has reasonable cause to suspect abuse, neglect, exploitation, abandonment, or suspicious or unexpected death has occurred with a UPMC CHC participant must: 1. Take immediate action to ensure the participant’s health and safety. If the participant’s health or well-being is in imminent danger, notify emergency first responders (911). 2. Make a verbal report to the state Adult Protective Services Hotline at 1-800-490-8505. Any questions requiring immediate attention outside of regular business hours should be directed to the APS contractor, Liberty Healthcare’s on-call staff at 1-888-243-6561. Please note this number should only be used for emergency situations requiring immediate attention. 3. Then contact the participant’s UPMC CHC service coordinator within 24 hours or make a verbal report to UPMC CHC Member Hotline at 1-844-833-0523 within 24 hours. • At a minimum, the verbal report must include participant’s full name, date of birth, date and time of incident, a brief description of the incident, participant’s current condition, and actions taken to mitigate risk to the participant; and • The reporter’s name, agency, and contact information. Copyright 2018 UPMC Health Plan Inc. All rights reserved. CHC RV CRT IDNT RT BR 17MA0213 (MCG) 1/4/18 U.S. Steel Tower, 600 Grant Street Pittsburgh, PA 15219 4. Submit a critical incident report in EIM and notify CHC no later than 48 hours following the discovery of the incident. *If using EIM, the provider has 48 hours to complete the report. • If the EIM system is down or your log in is not working, submit a critical incident using our form. Forms are located on the CHC Provider Services website and can be submitted through a secure email to or by fax to 412-454-5357. Possible Actions Needed To protect the safety of the member, a provider may need to take immediate actions that include but are not limited to the following: • Contact 911 if the incident can cause or did cause immediate/severe harm to the participant. • Remove worker from the participant’s services (if incident includes allegation of improper behavior by that worker). • Remove accused worker from servicing any UPMC CHC participant until the investigation is complete. This may take up to 30 calendar days. • Interview involved employee(s) as soon as possible following the incident. • Have the employee(s) submit a written account of events. - Electronically submit these written accounts to UPMC CHC. • Written accounts can be submitted through a secure email to or by fax to 412-454-5357. Follow-up Responsibilities Providers must cooperate fully in the investigation of reported critical incidents, including submitting all requested documentation within timelines specified. If the incident involves an employee of a HCBS provider, the provider must also submit a written report of the incident including actions taken within 20 calendar days of the incident. Based upon the severity of the incident, any identified trend or failure on the part of the provider to cooperate with any part of the investigation, the provider may be required by UPMC CHC to submit a written plan of correction to address and correct any problem or deficiency surrounding the critical incident.