Subject: Risk Prevention and Management

COA: PQI 4.02, RPM 2, RPM 2.01, RPM 2.02, RPM 2.03, BSM 1 Applies to: Entire organization

Incident/Accident Reporting and Monitoring

Effective: June 27, 2007 Revision effective: May 4, 2012 Reviewed: May 2, 2012 (Note: Task Force assigned for further review in Spring 2012.)

PURPOSE:
The purpose of the corresponding procedures is to provide operational guidelines for reporting incidents and accidents.

POLICY:
As part of its risk prevention and management activities, CCFW requires that an incident/accident report be completed to document, report, and assist in the evaluation of all incidents and/or accidents involving clients, employees, volunteers, or visitors. Employees are expected to know and comply with the incident/accident reporting procedures outlined in this document, and to assist other stakeholders in the reporting process as appropriate, necessary and/or requested. Incident/accident reports will be reviewed by appropriate level managers as outlined in the accompanying procedures. Incident/accident reports will also be reviewed quarterly to determine patterns, trends, and corrective actions needed as outlined in the CCFW Performance and Quality Improvement Plan and the CCFW Risk Management Plan.

SCOPE:
The corresponding incident and accident procedures apply to all departments and programs of Catholic Charities.

DEFINITIONS:
N/A

PROCEDURES:
General guidelines 1. The Client Incident/Accident Report and the Employee/Volunteer Incident/Accident Report is to be completed by the staff person witnessing and having the most information about what occurred. All sections of the form must be completed. If a particular section does not apply, denote with a N/A. All incident/accident reporting forms must be signed by the person preparing the report, the program/work group manager, department director, and the Vice President of Quality Assurance. 2. Facts regarding the incident/accident shall be documented in the case notes* in the stakeholders file including: a. Date of incident/accident; b. Type of incident/accident;

c. Individuals involved (only the client whose file is being documented should be identified by name; others should be de-identified); d. Individuals notified; e. Summary statement of action taken on behalf of the organization; and f. Date incident/accident report was submitted to Quality Assurance. *NOTE: The incident/accident report is not to be filed in the case record.) 3. All incidents/accidents are required to be reported verbally through the chain of command for the division (i.e Supervisor, Manager,Director, Vice President, and President/CEO). The President/CEO must be informed within 2 hours for any incident/accident that requires immediate medical treatment or if the incident/accident poses a serious risk of harm to the stakeholder. 4. Client Incident/Accident Reports and the Employee/Volunteer Incident/Accident Reports are completed and forwarded to Vice President of Quality Assurance within 24 hours of notification of the incident. The Vice President of Quality Assurance will maintain a summary spreadsheet of all incidents/accidents received and will keep the incident/accident forms in a locked filing cabinet in the office of the Division of Quality Assurance. For performance and quality improvement purposes the Division of Quality Assurance will complete a data analysis of all incidents and accidents on a quarterly basis and submit the results to the appropriate Performance and Quality Improvement Committee for review/recommendations. The following examples identify which incident/accident analysis reports are forwarded to: Client Services Committee runaway; incidents related to manual restraint (attach physical restraint form); medication error/issue; suicide attempts/gestures/threats; alleged abuse/neglect; altercations (unruly behavior of a client)

Safety Committee fire; destruction of property/vandalism; assaults (clients, employees, volunteers, or visitors); contraband (use or possession of illegal drugs or paraphernalia); exposure to blood borne pathogens (need sticks, etc.); birth/death on premises; accidental injuries to clients, staff, visitors, or volunteers in agency facilities; theft; harassment; altercations (unruly behavior of an employee/volunteer/donor); and vehicle accidents.

The Chair of the appropriate Performance and Quality Improvement subcommittee will provide a summary of such reports and recommendations to the PQI Committee on a quarterly basis, with an annual report to the Board of Directors. 5. Incident/accident reports are considered part of the agencys risk management program. As such they are subject to the confidentiality, records, and immunity guidelines outlined in CCFWs Risk Prevention and Management Plan.

Special situations and timeframes 1. If a client/staff/volunteer/visitor requires emergency medical assistance, a person will be requested to dial 911. Whenever possible, First Aid and CPR are rendered pending the arrival of the Emergency Medical Service Provider. 2. The President/CEO must be informed within 2 hours for any incident/accident that requires immediate medical treatment or if the incident/accident poses a serious risk of harm to the stakeholder. 3. If an employee or volunteer is injured, immediate verbal notification to Human Resources is required. The report is provided to Human Resources within 24 hours of the occurrence. Human Resource will then submit a copy to the Vice President of Quality Assurance within 24 hours of notification of the accident for PQI purposes. 4. If an incident/accident involves facilities or vehicle use for business, the employee must notify the Business Manager within 1 hour and submit the report the Business Manager within 24 hours of the incident. The Business Manager will then submit a copy to the Vice President of Quality Assurance within 24 hours of notification of the accident for PQI purposes. 5. If an incident/accident involves a minor client, or an client with a legal guardian, the legal guardian of the client is informed of the occurrence within 24 hours and such notification documented both in the case record and on the incident/accident report form. Texas Department of Family and Protective Services is notified as necessary to meet mandatory reporting laws for children, the elderly, and the disabled. 6. If an incident/accident involves a restrictive behavior intervention, a restraint documentation and follow-up form must accompany the incident/accident report.