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Section Risk Management Policy number 2-H Topic Critical Incidents Last Review Date 06/19/16 Last Revision Date 07/03/13 CARF Standards 1.H.4.b.(5-6), 1.H.9-10 Purpose 1. 2. 3. 4. 5. The purpose of the procedure is to provide staff with the information required to adequately address issues surrounding critical incidents. Critical incidents include the following: a. Elopement: client ran or wandered away during a session b. Injuries: staff, client, or others were injured during a session c. Violence: client or others became dangerously aggressive during a session d. Sexual Assault: client or others became sexually aggressive during a session. e. Suicidal: client or others indicated high suicide risk indicators during a session or phone call f. Weapons: client or others possessed, threatened with, or used a weapon during a session g. Substance use: client or others used, possessed, or appeared under the influence of alcohol/drugs during a session h. Restraint: staff used physical restraint with client or other during a session, which is a violation of agency policy i. Seclusion: staff used seclusion with client or other during a session, which is a violation of agency policy j. Vehicle accident: staff had a car accident going to or returning from a client session k. Infectious disease: staff was exposed to a communicable disease during a session l. Hazardous material: staff was exposed to hazardous material during a session m. Abuse/neglect reporting: staff called abuse hotline to report abuse, neglect or exploitation against a child or disabled or elderly adult n. Foster parent report: staff called abuse hotline to report misconduct by a foster parent against a child in custody o. Potential legal liability: staff have information that may result in adverse action against the agency or its staff Staff are required to perform the following actions in response to critical incidents: a. Session incidents (a-h above): Contact the Clinical Supervisor within 24 hours and turn in a completed Incident Report within 1 week b. Health & safety incidents (i-k above): turn in a completed Incident Report within 1 week c. Abuse reporting (l-n above): Contact the Clinical Supervisor before calling abuse hotline and turn in a completed Incident Report within 1 week d. Other incidents (o above): Contact the Program Manager within 24 hours and turn in a completed Incident Report within 1 week Supervisory staff who receive a report of a critical incident conduct a debriefing and training with the staff involved regarding possible actions that could have prevented the incident and may be used to prevent future incidents. This discussion is documented in the Follow-up section of the Incident Report. Staff with repeated incidents may be required to complete additional training, participate in additional clinical supervision, or be subject to disciplinary action. All staff receive competency-based training at hire and annually regarding identification and reporting of critical incidents. Proof of training is maintained in personnel file. Prevention of critical incidents is provided through annual training of staff in the following: Risk Management – Critical Incidents a. b. 6. Personal safety plan for clients Personal safety procedures for staff, including identification of unsafe environmental factors c. Violence prevention & intervention, including de-escalation strategies d. Personal health, including infection prevention & control An analysis of critical incident reports is included in the is included in the Annual Health & Safety Report and includes the following elements: a. Causes b. Trends c. Actions for improvement, including training needed for staff and strategies to reduce/prevent future recurrences d. Results of the previous performance improvement plan e. Compliance with internal & external reporting requirements Risk Management – Critical Incidents 1.H.4.b.(5) 1.H.4.b.(6) 1.H.9.a 1.H.9.b 1.H.9.c 1.H.9.d 1.H.9.e 1.H.9.f.(3) 1.H.9.f.(4) 1.H.9.f.(5) Personnel receive documented competency-based training in identification of critical incidents Personnel receive documented competency-based training in reporting of critical incidents The organization has written procedures regarding critical incidents that include prevention The organization has written procedures regarding critical incidents that include reporting The organization has written procedures regarding critical incidents that include documentation Critical Incidents, Staff Training Critical incidents, Staff Training Critical incidents The organization has written procedures regarding critical incidents that include remedial action The organization has written procedures regarding critical incidents that include timely debriefings conducted following critical incidents The organization has written procedures regarding critical incidents that include use of restraint The organization has written procedures regarding critical incidents that include incidents involving injuries The organization has written procedures regarding critical incidents that include communicable disease Critical incidents 1.H.9.f.(6) The organization has written procedures regarding critical incidents that include infection control 1.H.9.f.(7) The organization has written procedures regarding critical incidents that include aggression or violence 1.H.9.f.(8) The organization has written procedures regarding critical incidents that include unauthorized use or possession of weapons 1.H.9.f.(9) The organization has written procedures regarding critical incidents that include wandering The organization has written procedures regarding critical incidents that include elopement The organization has written procedures regarding critical incidents that include vehicular accidents The organization has written procedures regarding critical incidents that include biohazardous accidents The organization has written procedures regarding critical incidents that include unauthorized use or possession of legal or illegal substances 1.H.9.f.(10) 1.H.9.f.(11) 1.H.9.f.(12) 1.H.9.f.(13) 1.H.9.f.(14) 1.H.9.f.(15) 1.H.9.f.(16) 1.H.9.f.(17) 1.H.9.f.(18) 1.H.10.a 1.H.10.b.(1) The organization has written procedures regarding critical incidents that include abuse The organization has written procedures regarding critical incidents that include neglect The organization has written procedures regarding critical incidents that include suicide or attempted suicide The organization has written procedures regarding critical incidents that include sexual assault The organization has written procedures regarding critical incidents that include other sentinel events A written analysis of all critical incidents is provided to or conducted by the leadership at least annually A written analysis of all critical incidents is provided to or conducted by the Critical incidents Critical incidents Critical Incidents Critical incidents Critical incidents Critical incidents, Infection Prevention & Control Critical incidents, Infection Prevention & Control Critical incidents, Clinical Emergencies Critical incidents, Substance Use & Weapons Critical incidents Critical incidents Critical incidents Critical incidents, Hazardous materials Critical incidents, Substance Use & Weapons Critical incidents Critical incidents Critical incidents, Clinical Emergencies Critical Incidents Critical incidents Critical incidents Critical incidents Risk Management – Critical Incidents 1.H.10.b.(2) 1.H.10.b.(3) 1.H.10.b.(4) 1.H.10.b.(5) 1.H.10.b.(6) 1.H.10.b.(7) 1.H.10.b.(8) leadership that includes causes A written analysis of all critical incidents is provided to or conducted by the leadership that includes trends A written analysis of all critical incidents is provided to or conducted by the leadership that includes actions for improvement A written analysis of all critical incidents is provided to or conducted by the leadership that includes results of performance improvement plans A written analysis of all critical incidents is provided to or conducted by the leadership that includes necessary education and training of personnel A written analysis of all critical incidents is provided to or conducted by the leadership that includes prevention of recurrence A written analysis of all critical incidents is provided to or conducted by the leadership that includes internal reporting requirements A written analysis of all critical incidents is provided to or conducted by the leadership that includes external reporting requirements Critical incidents Critical incidents Critical incidents Critical incidents Critical incidents Critical incidents Critical incidents Risk Management – Critical Incidents