Quality in Managed Long-Term Services and Supports Programs. B. Critical Incident Review and Investigation

11/01/2013

In recent years, CMS has placed substantial emphasis on the importance of critical incident management processes in the 1915(c) HCBS waiver programs. With CMS' MLTSS guidance, this expectation now extends to MLTSS programs.

At a minimum, it is expected that there are provisions for the mandatory reporting of abuse, neglect or exploitation involving program participants. Robust critical incident management systems have structures and process in place for the receipt of reports and for their investigation, as well as protocols for urgent response when a member's health or safety is in immediate jeopardy.

The MLTSS study programs substantially delegate this responsibility to the MCOs. The states then monitor the MCO's management of critical incidents when they conduct audits and/or review MCO reports. Some states require the MCO to report certain events immediately or within 24 hours of their occurrence. For example, Wisconsin requires the MCO to report "egregious" incidents immediately. Michigan requires reporting certain deaths within 24 hours (i.e., those that occur as a result of suspected provider action/inaction and those that are the subject of a recipient's rights, licensing or police investigation). In Tennessee, any death or incident that could significantly impact the health or safety of a member must be reported to the state within 24 hours.

States vary in their approaches to overseeing the MCO's management of critical incidents. Several states require quarterly critical incident reports from the MCO (Tennessee, Texas, Wisconsin). Michigan requires reports to be submitted within 60 days following the end of the month when the incident occurred. In addition to requiring quarterly reports from MCOs, Tennessee also conducts semi-annual audits of the MCO's handling of critical incidents.

Only one program--Pennsylvania--has a centralized web-based system that serves as the repository for critical incident reports that must be submitted by the MCO within 24 hours. This system allows both the MCOs and the state to monitor how critical incidents are managed and resolved.

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