6143 Documenting a MFP Sentinel Event Report | ACCESS-TO-SERVICES-5200-MANUAL
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Georgia Division of Aging Services |
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Chapter: |
6000 Community Transitions |
Effective Date: |
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Section Title: |
Documenting a MFP Sentinel Event Report |
Reviewed or Updated in: |
MT 2016-02 |
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Section Number: |
6143 |
Previous Update: |
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Summary Statement
Money Follows the Person Field staff uses the Sentinel Event Report (SER) to communicate critical incidents to Division of Aging Services, Department of Community Health, and the Centers for Medicaid and Medicare Services.
Basic Considerations
A sentinel event is defined as one of the following:
Definitions
- Abuse
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As defined by OCGA 30-5-3 (1); refer to Adult Protective Services Manual, Chapter 1, Section 2001.5.
- Neglect
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As defined by OCGA 30-5-3 (9); refer to Adult Protective Services Manual, Chapter 1, Section 2001.5.
- Exploitation
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As defined by OCGA 30-5-3 (8); refer to Adult Protective Services Manual, Chapter 1, Section 2001.5.
- Hospital/Nursing Facility/ICF Admit
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Participant is admitted to a hospital, nursing (or skilled nursing) facility, long-term acute care, in-patient hospice, or similar facility for more than twenty-four (24) hours.
- Emergency Room Visit
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The MFP Participant visits an emergency room seeking treatment, prescriptions, or other medical care. The Participant need not receive services for a SER to be completed.
- Death
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An MFP Participant is confirmed as deceased by a local medical authority.
- Involvement with the Criminal Justice System
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An MFP Participant encounters law enforcement, accesses criminal legal services, violates probation or parole, or becomes involved in any other incident that involves the criminal justice system not to include misdemeanor traffic violations.
- Medication Administration
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An MFP Participant encounters difficulty with the administration of their medication or abuses their medication. This includes when insufficient medication is sent on day of transition.
- Other
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The TC believes a critical incident has occurred but cannot explain it with one of the categories above. TCs may also use 'Other' to notify DAS and DCH as to Medicaid conversion issues that prevent Participants from receiving scheduled services.
Standards of Promptness
All MFP Sentinel Event Reports are submitted to DAS within three (3) business days of the time the sentinel event becomes known to the TC. The date of the incident and the date of the report are listed separately on the MFP Sentinel Event Report.
Reporting Standards
All MFP Sentinel Event Reports will be logged into Harmony for MFP. DAS will not accept scans of paper copies of a Sentinel Event Report.
The original SER document should be updated as often as necessary to capture updates to the initial event described. Additional SERs are not required unless information becomes available that would trigger a second SER category.
AAA Procedures
The procedures below are formatted to follow the flow of the official SER report document. The standards are the guide by which the document is completed.
Process By Category
Abuse/Neglect/Exploitation
As mandated reporters, MFP Field staff are required to report any instances of abuse, neglect, or exploitation to Adult Protective Services and law enforcement in addition to the programmatic reporting done through the SER. If an MFP Participant is a victim, or the TC suspects they are a victim, of abuse, neglect, or exploitation a SER must be completed.
Hospital / Nursing Facility / ICF Admission
If the MFP TC discovers the Participant has been admitted to a facility, for any reason, a SER is completed.
If the admittance to an inpatient facility exceeds thirty (30) calendar days, the TC submits a Participant Status Change.
Emergency Room Visit
If the MFP Participant visits an emergency room seeking treatment, prescriptions, or other medical care, the TC submits a SER for the incident.
If the Participant is released without treatment, a SER must still be completed.
If the Participant is admitted to the hospital through the ER, report the incident under Hospital/Nursing Facility/ICF Admit, not Emergency Room Visit.
Death
If an MFP Participant dies, for any reason, a SER must be completed.
TC submits a preliminary SER within the standards of promptness, even if all information is unavailable. An update to the record may be submitted once additional information has been obtained.
Involvement with the Criminal Justice System
If an MFP Participant encounters law enforcement, accesses criminal legal services, violates probation or parole, or becomes involved in any other incident that involves the criminal justice system, the TC must complete a SER.
TC submits a preliminary SER within the standards of promptness, even if all information is unavailable. An update to the record may be submitted once all information has been obtained.
Medication Administration
If an MFP Participant encounters difficulty with the administration of their medication or abuses their medication, submit a SER under this category.
If the issue with medication administration results in an immediate ER visit or hospitalization, report the incident under the most appropriate category.
Summary / Participant Reporting / Adverse Outcomes
| Step 1 |
The MFP TC makes contact with the principal individuals associated with the Sentinel Event to determine the facts of the incident. Principal individuals may include the related physician, personal support aide, case manager, facility staff, family, friends, or other members of the circle of support. TCs are expected to investigate the incident thoroughly to provide complete and informative documentation related to the event. |
| Step 2 |
If the TC is unable to make contact with the principals prior to the standards of promptness, this is noted on the report, and the report submitted. An update to the report is then submitted once additional information is obtained. |
Witnesses
List individuals who witnessed the event or originally discovered the status of the Participant.
Action Plan
| Step 1 |
An action plan must be developed to address the root cause of the sentinel event. The action plan is documented on the MFP Sentinel Event Report. |
| Step 2 |
If it is determined that an MFP Transition Service could be utilized to help address the root cause, the TC then:
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Process Improvement
Document if there are processes that could be improved based on the results of the SER investigation. Recommendations need not be limited to MFP.
MFP Field Staff receive Serious Incident Review Team recommendations from DAS staff. Field Staff respond to SIRT recommendations as though they were a Corrective Action Plan request.
DAS Procedures
The following are the process and procedures by which DAS MFP Program staff will evaluate SERs as delivered in the data system.
SER Review
MFP Program Specialist reviews SER documentation monthly. SER reviews answer the following questions:
| Q 1 |
Is data reportable to Department of Community Health (DCH) accurate? |
| Q 2 |
Were standards of promptness observed? |
| Q 3 |
Did the Transition Coordinator (TC) adhere to policy and procedure in response to the event? |
| Q 4 |
If an action plan was required, was it conducted using a person centered approach using independent living philosophy? |
| Q 5 |
Are Journal notes surrounding the event informative and written according to standards and/or training? |
If deficits are noted, a Plan For Improvement (PFI) is drafted based on the elements above. A PFI is a statement from DAS informing the AAA that deficits exist. The PFI is an informative tool only. The PFI refers to standards, policy, procedure, or general practice for review at the discretion of the MFP Program Specialist.
If significant deficits are present or multiple PFIs indicate more significant action is necessary, a Corrective Action Plan (CAP) is drafted. A CAP is requested of the staff at the AAA to address the deficits in the program. The CAP is a plan with specific, measurable goals to address the deficit within a reasonable timeframe.
DAS MFP staff submit SIRT recommendations to MFP Field Staff in the format of a CAP request.
MFP Program Specialist will report SER status through the SIRT process.
References
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Policies and Procedures for Money Follows the Person (MFP Manual), dch.georgia.gov/georgia-money-follows-person-ga-mfp
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Harmony for MFP User Guide v1.x, Section 1060 (MAN 5600), Appendix I