Reporting Resident-Specific Incidents or Residence-Wide Emergencies to Elder Affairs
651 CMR 12.04(11)(c) and (d)
June 4, 2007
The following Q&A describes some of the regulatory context of reportable incidents. This document was issued after the 2006 regulation revision.
Note: some of the reporting protocols below are outdated and will be revised. We have flagged items that are expected to be revised in red italic text.
1. Does making a report to the Certification Unit at Elder Affairs replace any of our responsibilities to report to other agencies?
No. Reporting an incident to the Certification Unit at Elder Affairs does not replace any independent obligations to make other reports required under law.
2. What is the overall purpose of requiring Resident-specific incident reports? What types of Resident-specific incidents need to be reported to the Certification Unit at Elder Affairs?
The principal purpose of this requirement is to ensure that the Assisted Living Certification Unit is apprised of issues that, alone or in the aggregate, may be significant to its assessment of each Residence’s provision for the health, safety, and welfare of its Residents. The requirement therefore enables the Assisted Living Certification Unit more effectively to assess the Residence’s compliance with certification standards, and to be notified promptly about serious incidents that might require follow-up.
A Residence must report to the Certification Unit at Elder Affairs the occurrence of an incident or accident that has or may have a “Significant Negative Effect” on a Resident's health, safety or welfare. Note that there are two criteria which must be met in order for a situation to necessitate the filing of a Resident incident report:
(a) There was an incident* or accident; in other words, a distinct and unanticipated event; and,(b) The result of the incident* or accident was a Significant Negative Effect for a Resident.*For the purpose of determining reporting requirements, a situation that is solely the onset of a medical condition (e.g., a heart attack) is not an incident.
We encourage Residences to confirm that both of the above criteria are present before making a report. If an incident meets only (a) or (b), it does not need to be reported to Elder Affairs.
3. What is a “Significant Negative Effect”?
See the “definitions” section of the Regulations. It is a “situation in which a person is at significant risk of:
Death,
Immediate and serious physical harm, or
Immediate and serious emotional harm.”
The definition also lists events which represent or could lead to the above and which, if applicable, would need to be reported.
4. Please provide examples of situations that must be reported.
The following are examples of situations which must be reported:
A Resident falls and, as a result, is provided with an unplanned or unscheduled visit to a hospital, clinic, or physician’s office.
A Resident falls and, as a result, experiences serious physical harm, serious emotional harm, or death.
A Resident has an accidental injury and, as a result, is provided with an unplanned or unscheduled visit to a hospital, clinic, or physician’s office.
A Resident has an accidental injury and, as a result, experiences serious physical harm, serious emotional harm, or death.
A Resident is assaulted and, as a result, requires police involvement or is provided with an unplanned or unscheduled visit to a hospital, clinic, or physician’s office.
A Resident’s Unit is vandalized and (s)he exhibits signs of emotional trauma as a result.
There is a medication management error (SAMM or LMA) and, as a result, the Resident is provided with an unplanned or unscheduled visit to a hospital, clinic, or physician’s office.
A Resident is missing and it is reasonable to believe that he or she may be in danger of physical or emotional harm.
A Resident attempts to or does commit suicide. The above list is not exhaustive. Consistent with the response to FAQ 2 in this section, the Residence should consider the principal purpose of the incident reporting requirement in determining whether or not a specific situation should be reported.
5. Do we need to report every fall or other incident or accident?
No, only those incidents or accidents that cause a Significant Negative Effect. For example, a fall that causes no injury and no serious emotional harm need not be reported. Although it could reasonably be classified as an incident, it did not cause a Significant Negative Effect.
6. Do we need to report every unplanned or unscheduled trip to a hospital, clinic, or physician’s office?
No, only if the unplanned or unscheduled trip is the result of an incident. For example, a situation in which a Resident is sent to the hospital because (s)he experiences or exhibits shortness of breath, chest pain, nausea, weakness, fever, sudden confusion, or general decline in health status does not require a report, as long as it did not result from an incident.
7. Do we need to report every Significant Negative Effect, such as an unanticipated death?
No, only if it is the result of an incident. An example of a Significant Negative Effect that need not be reported is a Resident who, unrelated to an incident or accident, experiences a stroke or heart attack.
8. Do we need to report as an “elopement” all situations in which a Resident’s location is unknown?
No, not all. First, many Residents may routinely and appropriately come and go from Residences, presumably without telling the Residence. Others may inform the Residence of an anticipated time of return, but choose to stay away longer or encounter delays in their activities.
On the other hand, the Residence should be aware of which Residents have physical or cognitive issues that would warrant concern for those Residents’ safety and well-being if their location is unknown and if they are not known to be with family or other supportive persons.
9. Do we need to report incidents or accidents that do not occur on the property of the Residence?
Incidents or accidents which do not occur at the Residence and are not associated with the Residence’s property need not be reported. For example, suppose that the Resident is on a shopping trip, falls getting out of the van, and needs medical treatment. If the Resident has fallen getting out of the Residence’s van, it must be reported. On the other hand, if the Resident took the trip in a family member’s van, it does not need to be reported.
10. How do we make a Resident-specific incident report to the Certification Unit at Elder Affairs?
Authorized users must login to the ALR System to submit an Incident Report. The URL is: https://umassmedcwm05.crm.dynamics.com/. Detailed instructions are available in the ALR Dynamics User Guide.
11. What information needs to be included on the Resident-specific incident written report to the Certification Unit at Elder Affairs?
The report should not include the Resident’s name, but must include all of the following information:
The name and location of the Residence;
The date and time of the incident or accident;
A numeric identifier (or other unique identifier in place of the Resident’s name) to identify the Resident(s) involved in the incident;
The nature of the incident or accident;
Any remedial action taken;
The Resident’s status (e.g., “admitted to the hospital,” “remains at Residence,” “appointment to see MD tomorrow,” or “family notifying MD”) at the time the report is made to Elder Affairs;
List of other parties or agencies contacted; and,
The name and phone number of the person at the Residence to contact if additional information is needed by Elder Affairs.
12. What Residence-wide emergency situations should be reported? How soon and in what manner?
Report any Residence-wide emergency situation that displaces one or more Residents from their Units for 24 hours or more.
(The protocol below will be be updated.)
Residence-wide emergency situations must be reported immediately to the Certification Unit at Elder Affairs by telephone and in writing by the method described in the response to FAQ 10 in this section.
Residence-wide emergency situations should also be reported immediately to the Assisted Living Ombudsman Program at Elder Affairs by calling the Elder Affairs main number at 617-727- 7750.
13. What information must be included in a written report about a Residence-wide emergency situation?
To the extent known, provide the following:
The name and location of the Residence;
The date and time the emergency began or was identified;
The nature of the problem;
The number of Residents displaced;
A numeric identifier (or other unique identifier in place of the Resident’s name) to identify each of the is placed Residents so that Elder Affairs can track each such Resident;
The number of GAFC Residents displaced;
The number of Units rendered unusable due to the occurrence, and the anticipated length of time before the Residents may return to them;
Remedial action taken by the Residence;
Other State or local agencies notified about the problem; and
The name and phone number of the person at the Residence to contact if additional information is needed by Elder Affairs; and,
The current location(s) of all Residents displaced. (As noted above, each such Resident should be designated by numeric identifier (or other unique identifier), rather than by Resident name.)
14. How do we make an abuse or neglect report?
As always, reports of alleged or actual abuse or neglect must be reported directly to the appropriate Protective Services agency. The Elder Abuse Hotline is: 1-800-922-2275 (V/TDD).
You must also report abuse or alleged abuse to Elder Affairs pursuant to the Resident-specific incident reporting requirements outlined in the response to FAQ 10 of this section.
15. Do we have to make a separate report to the Group Adult Foster Care (GAFC) Program?
Yes. Although the MassHealth GAFC Program and Assisted Living Residence Certification are both overseen by staff of Elder Affairs, the programs are distinct, and the requirements are different. Assisted Living Residences that are MassHealth-approved GAFC Providers, therefore, must also adhere to reporting requirements set out in the GAFC guidelines, Bulletins, and other related MassHealth instructions. GAFC Providers must submit reports of emergency situations regarding Residents who receive GAFC services, and necessary follow-up documentation, according to those instructions, as well as according to the requirements for Assisted Living. GAFC Providers may contact the MassHealth Customer Service Team at 1-800-841-2900 with any questions about the GAFC program.
source: http://www.mass.gov/elders/regs-stats/housing/final-assisted-living-regulations-2006.html.