Incident Reporting, Adverse Events, and Investigations
Sets out how staff report incidents and adverse patient events on Form MI-HH-QA-02-A, what the clinical manager does first, which events also go to an outside authority (suspected abuse, neglect or exploitation; crimes; licensee misconduct; work injuries; privacy breaches; Michigan Medicaid provider preventable conditions), how events are investigated and when a root cause analysis is done, how patients and practitioners are told, and how incidents are tracked and analyzed in the QAPI program as 42 CFR §484.65 requires. Michigan has no separate incident reporting rule for home health agencies, so internal time frames are the Agency’s own standards.
- Policy number
- MI-HH-QA-02
- Version
- 1.0
- Main rule
- 42 CFR §484.65(c)(2)
- Library
- Michigan home health · 57 policies
- Category
- Quality
- Sections
- 19
In short
- Make the patient safe first. Call 911 for an emergency or a crime.
- Call the clinical manager or on-call nurse at once for a serious event, and before the end of your shift for anything else.
- Fill in the incident report with facts only: before the end of the shift for a serious event, within 24 hours for others.
- Suspected abuse, neglect or exploitation: call MDHHS Centralized Intake at 855-444-3911 yourself, right away.
- Keep anything involved, such as a broken device or a medication, for the investigation.
- Write a factual note in the patient’s record, but do not mention the incident report there.
What's inside
19 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (42 CFR §484.65(c)(2))
- 5. Immediate Action
- 6. Reporting Inside the Agency
- 7. Notifying the Practitioner and the Patient
- 8. Reports Outside the Agency
- 9. Review and Investigation
- 10. Classification, Tracking and QAPI
- 11. Confidentiality of Incident Reports
- 12. Responsibilities
- 13. Records and Compliance Monitoring
- 14. Staff Training
- 15. References
- 16. Related Policies and Forms
- 17. Approval
- 18. Revision History
An inspector may ask
- Show me your incident reports for the last quarter and how they were analyzed.
- Tell me about the last serious adverse event. What did you find was the cause and what did you change?
See Cura Core with your agency's name on it.
Choose your state and type of agency, buy your Policy Pack online and get your sign-in by email. Already a customer? Sign in to your portal.