{"ref":"LA-HH-QA-02","title":"Incident Reporting, Investigation, and Adverse Events","category":"Quality","summary":"Sets out how staff report, and how the Agency responds to, investigates, documents and learns from incidents and adverse patient events such as falls, injuries, injuries of unknown source, medication errors, equipment failures, exposures and property loss. Louisiana has no home health incident report to LDH, but an agency that has placed a patient at risk according to a documented incident may receive a provisional license (LAC 48:I §9105.B.2.c), and failing to notify an appropriate governmental agency of suspected neglect, criminal activity or abuse is a ground for immediate revocation (§9111.C.4). Abuse, neglect and exploitation are reported outside the Agency under Policy LA-HH-SG-01 within 24 hours (R.S. 40:2009.20). If the Agency is Medicare-certified, adverse patient events are tracked and analyzed under 42 CFR §484.65.","inShort":["Make the patient safe first. Call 911 in an emergency.","Call the clinical manager or the on-call nurse right away.","If abuse, neglect or exploitation may be involved, report it outside the Agency within 24 hours.","Complete an incident report before your shift ends, and within 24 hours at most.","Write facts only. Do not mention the incident report in the clinical note."],"primaryCitation":"LAC 48:I §9111.C","citations":["LAC 48:I §9111.C","LAC 48:I §9111.C.4","LAC 48:I §9105.B.2.c","LAC 48:I §9125.A.2","LAC 48:I §9123.E","LAC 48:I §9102.B.3","LAC 48:I §9102.B.3.c","LAC 48:I §9115.B.1.o","R.S. 40:2009.20"],"federalCitations":["42 CFR §484.50(e)(1)","42 CFR §484.50(e)(2)","42 CFR §484.65(a)(2)","42 CFR §484.65(c)(2)"],"surveyorAsks":["Show me your incident reports for the last quarter and what you did about each one.","An aide finds a bruise she cannot explain. What does she do, and who must be told outside the Agency?"],"forms":[{"ref":"LA-HH-QA-02-A","title":"Incident Report"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (LAC 48:I §9111.C)","5. What Must Be Reported","6. Immediate Actions","7. Writing the Incident Report","8. Investigation","9. Notifications Outside the Agency","10. Tracking, Trending, and Learning","11. Responsibilities","12. Records and Compliance Monitoring","13. Staff Training","14. References","15. Related Policies and Forms","16. Approval","17. Revision History"],"version":"1.0","sample":false,"pack":"la-hha","state":"Louisiana","service":"Home health","guides":[{"path":"/guides/home-health-qapi/","h1":"What is QAPI in home health, and what does §484.65 require?"},{"path":"/guides/home-health-agency-policies/","h1":"What policies and procedures are required for home health agencies?"},{"path":"/guides/home-health-conditions-of-participation/","h1":"Home health Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}