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PCPA Responds to Draft Incident Management Bulletin From OMR
September 13, 2000

Mr. Mel Knowlton
Department of Public Welfare
Office of Mental Retardation
PO Box 2675
Harrisburg, PA 17105-2675

Dear Mr. Knowlton:

The Pennsylvania Community Providers Association (PCPA) represents over 220 providers of service in mental retardation, mental health, and addictive disease. More than 85 of these members provide services licensed by the Office of Mental Retardation (OMR) and are therefore affected by the draft Mental Retardation Bulletin on Incident Management.

The following comments have been gathered from members of the Association in response to the draft released by OMR in July. We appreciate the opportunity to respond. PCPA salutes and supports the Department of Public Welfare's continued work to preserve and ensure the safety of the people in their care. However, serious concerns about the draft bulletin make it difficult to support pieces of this approach to that assurance of safety.

PCPA members, in awaiting the results of the incident report task group, expected the redefinition of what constitutes an incident in an effort to eliminate unnecessary reporting while making guidelines clear for investigations. After review of the draft bulletin, it appears that increased reporting and increased demands on providers are the result, with less clarity than currently exists within the system.

It is our hope, in the review of comments received from PCPA and others, that OMR staff will be able to address these significant issues. It is the belief of the provider system that many of the activities outlined in the bulletin are more appropriate as part of a quality improvement program within an agency, and not as additional reporting/monitoring tasks of the Office of Mental Retardation. Additionally, increased demands created by the bulletin will be difficult to achieve at current staffing levels. As you are aware, the service provision system is operating with high rates of turnover and vacancies in programs. The requirements contained in the bulletin place additional responsibilities on agencies that are already understaffed, undefended, and unable to spend time on activities beyond day-to-day service provision. Funding is not sufficient to maintain employees currently. Stretching that funding further is not possible. It is our belief that bulletin expectations and requirements cannot be achieved with current resources in the provider system.

The remainder of this document outlines specific concerns with the draft Incident Management Bulletin, and will be referenced by page number and topic heading.

Page 7, Reportable Incidents Defined

  • Emergency Closure – Providers are, at times, forced to relocate residents temporarily when there are staffing issues. This definition means that those also become reportable incidents.
  • Emergency Room Visits – This information could be more easily captured elsewhere, such as the quarterly summaries done on each individual already provided to the county.
  • Fire – Why does OMR want to know about small fires that are extinguished by agency staff and do not involve fire personnel?
  • Improper or Unauthorized Use of Restrains – Will this definition be consistent with the restraint guidelines being drafted by OMR?
  • Law Enforcement Activity – Reporting police activity that involves an on-duty employee is acceptable only if initials may be used and confidentiality maintained. There should be clarification that an arrest or legal involvement of a family caregiver that does not pertain to the person with MR would not be reportable.
  • Medical Conditions – The volume of incident reports that will be required to document visits to physicians will be very large. OMR may wish to redefine this expectation so that routine visits are also excluded, as are those of acute and chronic illnesses.
  • Medication Errors – Again, the volume of incident reports may be excessive. OMR could require providers to track and report medication errors as part of a quality improvement program, or include them in quarterly summaries provided for each individual. Providers should be required to have policies on medication errors that are satisfactory to OMR.
  • Missing Person – Please clarify if this includes situations where a person who requires supervision is left unsupervised.
  • Misuse of Funds – Property lost or discarded should be accounted for in a provider's inventory, which fiscal regulations and county government require to be maintained. Misuse of agency funds should not be reportable to OMR. Internal and external auditing controls should be sufficient to show compliance with fiscal regulations and appropriate use of funds.
  • Neglect and Physical Abuse – How does this relate to persons who live in their families’ homes? Are providers being asked to report families, conduct investigations, and ask families to comply with their rules? Does OMR intend that client-to-client abuse must be reported and investigated the same way as a staff-client incident?
  • Refusal of Prescribed Treatment – Regulations currently require that if someone refuses medical treatment there should be a plan to address the situation. Therefore, documentation is already included in the record. Many times prescribed treatment is refused. Does OMR truly expect to see incident reports on items such as refusing a mammogram, refusing to take medication, or refusing to go to day programming?
  • Verbal Abuse – Remove the word "intended" from the definition. It is not always possible to determine the intentions of the speaker. It is unclear whether this includes incidents of yelling, use of profane language, or name calling between clients.

Page 12, Reporting Requirements

  • There is a need for a clear reporting algorithm that outlines the reporting procedure. There is considerable confusion regarding dual reporting requirements and when either the county or provider is expected to report.
  • The draft bulletin requires reporting to families/guardians unless the individual asks for the information to remain confidential. In reality, there are some families who don't want that level of detailed information. Would OMR consider a recommendation to ask families/guardians upon admission what incidents they wish to be informed of or when they want to be contacted? Again, if listing incidents is part of the quarterly or annual reports already done for each individual, that information is present.

Page 15, Reporting Process

  • It is duplicative to have an Initial Notification Report and a Written Report.
  • Asking for names in the written report is not appropriate and breaches confidentiality of staff. If an abuse allegation is unfounded, why should the name of the person be documented as charged?
  • In the Final Report, the bulletin indicates that the autopsy report and death certificate must be included in the case of death. Providers are not always authorized to receive copies of these documents. Coroners often state legal reasons for not providing this information to the agency.
  • OMR should reconsider the requirement that final reports must be in the individual's record. All staff should not have access to incident reports that contain confidential disciplinary or corrective action.
  • Is the point person different than the investigator? Can one individual maintain both responsibilities in an organization?
  • 30 days may be too short a period of time to complete a final report if there is a complex investigation and multiple reporting requirements. It may be too soon to "close" some incidents, particularly if agency policies need to be modified and training done.

Page 21, Requirements for Certification

  • Certification has financial implications for providers. At a minimum, this includes time away from other duties and travel to a certified training program. Additionally, with turnover high, providers feel they would be very fortunate to maintain a certified investigator on staff for two years.

Page 21, Investigation Requirements

  • Is the investigators report the final report?
  • If not, why does OMR want an Initial, Written, Final, and Investigator's Report?
  • Why is the Investigation Record separate from the Individuals' Record, but Final Reports are required to be in the Individual's Record?

Page 22, Data and Information Analysis Requirements

  • Will OMR be funding MIS efforts in provider agencies?
  • Why, if as is stated in this section, "trend analyses provide the Commonwealth with insights that cannot be gained from the review of individual reports", are providers required to send individual reports to OMR?
  • Reporting to OMR is duplicative of the reporting already done to the county.
  • Regulations currently require that incidents be summarized every six months. This is sufficient. Quarterly is too burdensome and costly. The Commonwealth is only planning to review trends semi-annually as proposed.
  • The HCCU is responsible to access incident data on a monthly basis. Will the counties send them those reports? What about Consent to Release Confidential Information? Who must obtain that authorization?
  • The requirement to convene a management group to review all reports and investigations without additional staff resources for personnel and training may not be possible.

Page 26, Addendum 1

  • If the family is to assure that anyone providing service receives information about the reporting of incidents, there should be a clearly and simply written document that they can use for this purpose.

Again, we appreciate the opportunity to comment on the proposed requirements for Incident Management within the mental retardation service system. If I, or any member of my staff, can assist you in further clarification of these comments, please do not hesitate to call. We look forward to the revised document from OMR, and hope that it will again be available for public review before implementation.

Sincerely,

George J. Kimes
Executive Director

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