Adverse & Critical Incident Report

For Providers

Adverse & Critical Incident Report

Adverse & Critical Incident Report

­­­­­­­­­­­­­Network providers shall participate in and cooperate with Community Care Plan (CCP) Risk Management Program. Note that provider submission of adverse incident reports from the following providers: health maintenance organizations and health care clinics reporting in accordance with s. 641.55, F.S.; ambulatory surgical centers and hospitals reporting in accordance with s. 395.0197, F.S.; assisted living facilities reporting in accordance with s. 429.23, F.S.; nursing facilities reporting in accordance with s. 400.147, F.S.; and crisis stabilization units, residential treatment centers for children and adolescents, and residential treatment facilities reporting in accordance with s. 394.459, F.S. are not contractually required. Adverse incidents occurring in these licensed settings shall be reported in accordance with the facility’s licensure requirements.

DEFINITIONS                                                  

Adverse Incident: An injury of an enrollee occurring during delivery of CCP’s covered services that:

  1. Is associated in whole or in part with service provision rather than the condition for which such service provision occurred;
  2. Is not consistent with or expected to be a consequence of service provision;
  3. Occurs as a result of service provision to which the patient has not given his informed consent;
  4. Occurs as the result of any other action or lack thereof on the part of the staff of the provider;

Incidents include:

  1. Death;
  2. Brain damage;
  3. Spinal damage;
  4. Permanent disfigurement;
  5. Fracture or dislocation of bones or joints;
  6. Any condition requiring definitive or specialized medical attention which is not consistent with the routine management of the patient’s case or patient’s preexisting physical condition;
  7. Any condition requiring surgical intervention to correct or control;
  8. Any condition resulting in transfer of the patient, within or outside the facility, to a unit providing a more acute level of care;
  9. Any condition that extends the patient’s length of stay; and/or
  10. Any condition that results in a limitation of neurological, physical, or sensory function which continues after discharge from the facility

Critical Incident: Critical events that negatively impact the health, safety, or welfare of a Long-term Care Plan enrollee, including death by suicide, homicide, abuse/neglect or that is otherwise unexpected; adverse incident or major illness; sexual battery; medication errors; suicide attempts; altercations requiring medical intervention; or elopement.

After Hours: The hours between five PM (5pm) and eight AM (8am) local time, Monday through Friday inclusive, and all-day Saturday and Sunday. State holidays are included.

ADVERSE OR CRITICAL INCIDENT REPORT INSTRUCTIONS

If an Adverse or Critical Incident occurs to an enrollee, the Provider needs to report the incident, as required by CCP Risk Manager within twenty-four (24) hours after the incident, the provider must:

  1. Complete the Potential Quality Issue Form immediately when becoming aware of an Adverse or Critical Incident;
  2. Fill each blank on the form, using N/A when something is not applicable to the particular occurrence;
  3. Write legibly or type the information on the form;
  4. Describe with full details the Adverse or Critical Incident;
  5. Indicate the body part injured location and extent of injury and document fully, including lack of injury;
  6. Report any pertinent action taken in response to the occurrence;
  7. Obtain the name and location information for any witness, including employees;
  8. Sign and date the report. Include title/designation and contact phone number.
  9. Fax (within 24 hours) to CCP’s Risk Management confidential line at: 954-251-4161

Also,

  • Cooperate with the CCP’s Risk Management Program;
  • Provide such medical and other records without charge within ten (10) days of receipt of written notice;
  • Share such investigation reports and other information as may be required or requested by CCP’s Risk Manager to determine if an Adverse or Critical Incident is reportable to AHCA.

When an Adverse or Critical Incident Occurs

For assistance, if needed, in completing the Potential Quality Issue form, please contact CCP’s Risk Manager at 954-622-3336.

Note: Adverse or Critical Incident Reports (PQI) are part of risk management files only and copies of the Adverse or Critical Incident (PQI) Reports must be maintained separately from Enrollee’s medical record. Appropriate action will be initiated when indicated. Adverse or Critical Incident Reports (PQI) will not be used to penalize Providers; however, failure to report an Adverse or Critical Incident may result in further action by CCP.