The purpose of this policy is to establish guidelines for the internal review of incidents and emergencies.
This DAC is committed to the prevention of and safe and timely response to incidents and emergencies. Staff will act immediately to respond to incidents and emergencies as directed in the Policy and Procedure on Responding to and Reporting Incidents and the Policy and Procedure on Emergencies. After the health and safety of person(s) served are ensured, staff will complete all required documentation that will be compiled and used as part of the internal review process.
The DAC will ensure timely completion of the internal review procedure of incident and emergencies to identify trends or patterns and corrective action, if needed.
A. The Designated Manager will conduct a review of all reports of incidents and emergencies for identification of patterns and implementation of corrective action as necessary to reduce occurrences. This review will include:
1. Accurate and complete documentation standards that include the use of objective language, a thorough narrative of events, appropriate response, etc.
2. Identification of patterns which may be based upon the person served, staff involved, location of incident, etc. or a combination.
3. Corrective action that will be determined by the results of the review and may include, but is not limited to, retraining of staff, changes in the physical plant of the program site, and/or changes in the Coordinated Service and Support Plan Addendum.
B. Each Incident and Emergency Report will contain the following information:
1. The name of the person or persons involved in the incident. It is not necessary for staff to identify all persons affected by or involved in an emergency unless the emergency resulted in an incident.
2. The date, time, and location of the incident or emergency.
3. A description of the incident or emergency.
4. A description of the response to the incident or emergency and whether a person’s Coordinated Service and Support Plan Addendum or program policies and procedures were implemented as applicable.
5. The name of the staff person or persons who responded to the incident or emergency.
6. The determination of whether corrective action is necessary based on the results of the review that will be completed by the Designated Manager.
C. In addition to the review for the identification of patterns and implementation of corrective action, the DAC will consider the following situations reportable as incidents or emergencies which will require the completion of an internal review:
1. Emergency use of manual restraint as defined in MN Statutes, sections 245D.02, subdivision 8a and 245D.061. MN Statutes, section 245D.061, subdivision 6, has an internal review report requiring the answering of six questions.
2. Death and serious injuries not reported as maltreatment according to MN Statutes, section 245D.06, subdivision 1, paragraph g.
3. Reports of maltreatment of vulnerable adults or minors according to MN Statutes, sections 626.557 and 626.556.
4. Complaints or grievances as defined in MN Statutes, section 245D.10, subdivision 2.
D. When the DAC has knowledge that a situation has occurred that requires an internal review, the Designated Manager will ensure that an Incident and Emergency Report or Emergency Use of Manual Restraint Incident Report has been completed.
1. In addition to the Incident and Emergency Report, if there was a death or serious injury, the Designated Manager will also ensure that the applicable documents have also been completed for the MN Office of the Ombudsman for Mental Health and Developmental Disabilities and the Department of Human Services Licensing Division.
2. For internal reports of suspected or alleged maltreatment of a vulnerable adult, a copy of the Notification to an Internal Reporter will also be submitted for the internal review.
3. The internal review and reporting of emergency use of manual restraints will be completed according to the Policy and Procedure on Emergency Use of Manual Restraint.
E. Documentation to be submitted to the designated person responsible for completing internal reviews will include, as applicable:
1. Incident and Emergency Report.
2. Notification to an Internal Reporter.
3. Emergency Use of Manual Restraint Incident Report.
4. Death Reporting Form.
5. Serious Injury Form.
6. Death or Serious Injury Report FAX Transmission Cover Sheet.
7. Complaint Summary and Resolution Notice.
F. The Executive Director is the primary individual responsible for ensuring that internal reviews are completed for reports. If there are reasons to believe that the Executive Director is involved in the alleged or suspected maltreatment or is unable to complete the internal review, the Designated Manager is the secondary individual responsible for ensuring that internal reviews are completed.
G. The internal review will be completed (within 30 calendar days for maltreatment reports) using the Internal Review form and will include an evaluation of whether:
1. Related policies and procedures were followed.
2. The policies and procedures were adequate.
3. There is a need for additional staff training.
4. The reported event is similar to past events with the persons or the services involved.
5. There is a need for corrective action by the license holder to protect the health and safety of persons served.
H. Based upon the results of the review, the license holder will develop, document, and implement a corrective action plan designed to correct current lapses and prevent future lapses in performance by staff or the license holder, if any.
I. The following information will be maintained in the service recipient record, as applicable:
1. Incident and Emergency Report including the written summary and the Designated Manager’s review.
2. Emergency Use of Manual Restraint Incident Report and applicable reporting and reviewing documentation requirements.
3. Death Reporting Form.
4. Serious Injury Form.
5. Death or Serious Injury Report FAX Transmission Cover Sheet.
6. Complaint Summary and Resolution Notice.
J. Completed Internal Reviews and documentation regarding suspected or alleged maltreatment will be maintained separately by the internal reviewer in a designated file that is kept locked and only accessible to authorized individuals.
K. Internal reviews must be made accessible to the commissioner immediately upon the commissioner’s request for internal reviews regarding maltreatment.