9006 Serious Incident Review Team (SIRT) Process

Georgia State Seal

Georgia Division of Aging Services
Administrative Manual

Chapter:

9000 Forensic Special Initiatives Unit (FSIU)

Effective Date:

Section Title:

Serious Incident Review Team (SIRT) Process

Reviewed or Updated in:

2017-01

Section Number:

9006

Previous Update:

Summary Statement

The Division uses a standardized process for reviewing serious incidents of specified clients.

Purpose

The primary purpose of the Serious Incident Review Team (SIRT) is to review serious incidents to determine if incidents could have been prevented and what lessons can be learned to reduce future incidents. Additionally, the SIRT will utilize the review process as a quality assurance tool to determine if policies were followed, identify areas of non-compliance and identify opportunities for improvement in DAS programs. This will be accomplished through technical assistance and recommendations to involved parties and education of appropriate agencies and the community. The SIRT process is not intended to replace review processes within each program.

The SIRT recognizes that the responsibility for responding to and reducing adverse outcomes does not lie with any single agency or entity. It is further recognized that a careful examination of adverse outcomes provides the opportunity to develop education, prevention, and strategies that will lead to improved coordination of services to prevent or mitigate similar adverse outcomes in the future. Other possible benefits of SIRT include improved inter-agency case management, identification of gaps and breakdowns in agencies and systems designed to protect this population, and the development of data systems that can guide the formation of protocols and policy for agencies that serve this population.

Basic Considerations

SIRT Members

The SIRT shall include the following members:

  • The SIRT Facilitator

  • Public Guardianship Office (PGO) Program Owner and/or designee

  • Money Follows the Person (MFP) Program Owner and/or designee

The SIRT facilitator, DAS Director or Deputy Director may assign additional DAS program designees and/or other third parties as needed.

Scope

Clients for whom serious incidents or sentinel events must be reported include:

  • DHS clients under public guardianship case management through the Public Guardianship Office (PGO)

  • Nursing Home Transitions - Money Follows the Person participants currently in their 365-Day participation period.

Of the reportable incidents for each program, the SIRT Facilitator will review the following incidents:

PGO

  • Critical Incidents

  • Serious Injuries

  • Deaths

MFP

  • Three or more sentinel events for the same client

  • Re-institutionalization

  • Death

  • Allegations of abuse, neglect, or exploitation (A/N/E)

Definitions

Refer to Section 9001 in this manual.

Confidentiality

All communication, oral or written, and documents pertaining to SIRT are confidential and may not be disclosed outside the SIRT unless authorized or required by law.

Each SIRT member shall sign an agreement that he/she will abide by the confidentiality rule and will not discuss SIRT confidential information outside meetings nor disclose documents to third parties. The SIRT Facilitator will maintain the confidentiality agreements. Confidentiality agreements will be reviewed annually.

No SIRT report will contain individual identifying information.

Record Keeping

SIRT information is housed in a secure folder on the DAS shared system accessible by SIRT members only. The SIRT Facilitator is responsible for requesting security access for new members and removing former members.

Procedures

Reporting Serious Incidents

Each program utilizes procedures for reporting incidents specific to the policy and regulations for their program. Reporting criteria may be found in the following locations:

  • Public Guardianship: MAN 5800 Chapter 5050, Section 5070

  • Money Follows the Person: Georgia MFP Policy and Procedure Guide, Chapter 605.4

  • Access to Services: MAN 5200 Chapter 6140, Section 6143

SIRT Review

The following procedures will be followed:

Step 1

The SIRT Facilitator will review all SIRT eligible incidents. A Program Owner may request that a case not meeting SIRT criteria be reviewed. The SIRT Facilitator will notify the Program Manager whether the request is granted or not.
Step 2

The SIRT Facilitator will present the Program Owner or designee with any issues that need follow up and any suggested recommendations.
Step 3

The Program Owner or designee will provide the SIRT Facilitator with a follow up report regarding actions taken and any additional recommendations within four weeks of the SIRT Facilitator review.
Step 4

The SIRT will meet once a month. Using information from the incident reviews, the SIRT Facilitator will discuss trends and opportunities for improvement within and across programs. Trends associated with specific providers will be shared with other entities as appropriate.
Step 5

The SIRT Facilitator will provide a summary of each meeting.
Step 6

The SIRT members will review the summary and provide comments to the SIRT Facilitator.
Step 7

Recommendations that involve agencies outside of DAS will be forwarded to the DAS Director for consideration.

Report of Findings

The SIRT Facilitator will maintain a database of all recommendations made.

Reports

The following reports will be provided to the Division Director and Deputy Director:

SIRT meeting summaries: as soon as the summary is finalized

Quarterly report: a summary of recommendations and trends in data.

Annual report: Following each state fiscal year. The report will summarize all cases reviewed, trends, recommendations and recommendation status.

References

MAN 5200 Chapter 6140, Section 6143
MAN 5800 Chapter 5050, Section 5070
Georgia MFP Policy and Procedure Guide, Chapter 605.4