4

CMHA-CEI Policies and Procedure Manual

Title: 1.1.14, Sentinel Events

Subject: BOARD AND ADMINISTRATIVE OPERATIONS

Section: Administrative

Policy: □

Procedure: X

Issued by:

Director of Quality, Customer

Service, and Recipient Rights

Effective Date:

2/8/06

Applies to:

X All CMHA-CEI staff

□ Contract Providers

□ Other:

Page: 1 of 5

Approved by:

Board of Directors

Review Date:

12/9/16

I. Purpose: To identify a sentinel event, understand the cause, and take necessary action to reduce

the probability of a future reoccurrence. This procedure is in compliance with the standards

established by Mid-State Health Network (MSHN).

II. Procedures:

A. Initial actions to be taken when there is suspicion of a sentinel event (refer to Appendix A for

flowchart):

1. Any provider/contract provider will notify their direct supervisor immediately upon

suspicion of a Sentinel Event. An Incident Report will be completed and/or a

Recipient Rights Complaint, as needed.

2. All persons involved in the event will complete a first person account of the event as

soon as possible and within 72 hours of the event.

a. The goal of a first person account is to provide details about the event in a

clear, concise manner, giving as many details as you recall as accurately as

possible. Describe only what you actually witnessed.

b. Send the account directly to the QCSRR Director through secure email or

interoffice mail.

c. The first person account will be used by the QCSRR Director or Compliance

Officer to complete a timeline of events to better inform those conducing a

root causes analysis of the event.

d. All first person accounts will be peer review protected.

e. Only the QCSRR Director or Compliance Officer will review the first person

accounts.

f. All first person accounts will be kept confidential and locked in a filing

cabinet.

3. Peer review protected first person statements will be sent directly to the Quality,

Customer Service, and Recipient Rights (QCSRR) Director as soon as possible and

within 72 hours of the event.

4. The QCSRR Director will determine if the event qualifies as a sentinel event. The

QCSRR Director may involve others in this decision process.

5. If the event is determined to not meet the definition of a sentinel event, the Incident

Report Procedure (3.3.7) and process outlined in that procedure shall be followed or

the Recipient Rights Office will process allegations normally as described in the

Recipient Rights Procedure (3.6.1). The peer review protected first person statements

are not included in the processes outlined in procedures 3.3.7 and 3.6.1.

Procedure #: 1.1.14 Title: Sentinel Events

Page 2 of 5

B. Actions to be taken when it has been determined that a sentinel event occurred:

1. Within 3 business days of the sentinel event, the QCSRR Director will send

notification to the Chief Executive Officer (CEO), the Mid-State Health Network

(MSHN), and the Commission on the Accreditation of Rehabilitation Facilities

(CARF) that a sentinel event has occurred.

C. Actions to be taken if there is a Recipient Rights complaint or allegation:

1. The Recipient Rights office will process allegations normally as described in the

Recipient Rights Procedure, 3.6.1. The peer review protected first person statements

are not included in the process outlined in procedure 3.6.1.

2. Initiating the root cause analysis (RCA) process within 5 business days of the sentinel

event, consultation then occurs within the Review Group (RG) comprised of the

QCSRR Director, Medical Director, Compliance Officer, and Clinical Program

Director.

3. The Recipient Rights Office will work closely with the QCSRR Director to progress

the root cause analysis process as appropriate.

D. Actions to be taken when there is no Recipient Rights complaint or allegation:

1. Initiating the RCA process within 5 business days of the sentinel event, consultation

then occurs within the Review Group (RG) comprised of the QCSRR Director,

Medical Director, Compliance Officer, and Clinical Program Director.

2. The Review Group will identify an employee to review the event and complete

additional fact finding to compose a report that includes a timeline of events and a

list of those who had involvement in the event.

3. The report will be sent to the RG for review.

4. The RG will convene a meeting, with others attending as needed, to progress the

RCA process.

5. The root causes will be determined and action plans to address the root causes will

be implemented.

6. The RCA action plans are approved by the CEO.

7. RCA action plans are monitored by the Compliance Officer with oversight form the

Critical Incident Review Committee (CIRC).

E. Additional Sentinel event review and reporting may be required by accrediting bodies. This

is outside of the scope of this procedure and is the responsibility of the CEI Compliance

Officer or the Director of Quality, Customer Service, and Recipient Rights.

F. CMHA-CEI recognizes that some critical occurrences or incidences, not meeting the

definition of sentinel event, although not technically reportable to any state organization or

accrediting body, warrant a root cause analysis, plan of action, monitoring, and/or evaluation

to reduce the risk of its reoccurrence. The QCSRR Director will determine if incidences not

meeting the standard for sentinel event should have further actions.

III. Definitions:

A. Root Cause: The most basic reason for failure or inefficiency of a process.

B. Root Cause Analysis: A method of problem solving used to identify the root cause(s) of

faults or inefficiencies.

C. Sentinel Event: An unexpected occurrence to a recipient of services involving death or

serious physical (loss of limb or function) or psychological injury, or the risk thereof.

(Risk thereof includes any process variation that would most likely would result in a

Procedure #: 1.1.14 Title: Sentinel Events

Page 2 of 5

sentinel event if it reoccurred).

D. Recipient of Services:

1. A consumer is considered to an active recipient of services when any of the following

occur:

a. A face-to-face intake has occurred and the individual was deemed eligible for

ongoing service, or

b. CMHA-CEI has authorized the individual for ongoing service, either through

a face-to-face screening or a telephone screening, or

c. The individual has received a non-crisis, non-screening encounter.

2. The period during which the consumer is considered to be actively receiving services

shall take place between the following begin date and end date, inclusively:

a. Begin Date: Actively receiving services begins when the decision is made to

start providing ongoing non-emergent services. Specifically, the beginning

date shall be the first start date that any of the 3 conditions referenced above

occurs.

b. End Date: When the consumer is formally discharged from services. The date

the discharge takes effect shall be the end date. This should also be the date

that is supplied to the consumer when the consumer is notified that services

are terminated.

IV. Monitor and Review:

This procedure is reviewed annually by the Director of Quality, Customer Service, and Recipient

Rights. This procedure is monitored by accrediting bodies and regulatory agencies as applicable.

V. References:

A. 42 CFR 438.10: Information Requirements

B. 42 CFR 438.400: Appeals and Grievances

C. MA Contract 6.3: Customer Services

D. MSHN Procedure 603: Critical Incidents

E. PIHP Contract Attachment P 7.9.1: Quality Assessment and Performance Improvement

Programs for Specialty Pre-Paid Inpatient Health Plans

VI. Related Policies and Procedures:

CMHA-CEI Policy 1.1.14 Sentinel Events

CMHA-CEI Procedure 3.3.7 Incident Reporting

CMHA-CEI Procedure 3.2.08D Clinical Peer Review

Procedure #: 1.1.14 Title: Sentinel Events

Page 2 of 5 VI. Review Log

Review Date Reviewed By Changes (if any)

11/20/07

5/5/11

4/13/14

12/09/16

-

-

-

QI Specialist

-

-

-

Updating to new process, adding flow chart,

updating definitions and references, update

to new format

VII. Attachments:

A. CMHA-CEI Sentinel Event Root Cause Analysis (RCA) Process Flowchart

Attachment A

1.1.14, Sentinel Event Procedure page 4 of 4

Potential Sentinel

Event Occurs

Peer review protected

1st person accounts of

the event are

completed by all

involved and sent to

the QCSRR Director

ASAP, within 72 hours.

In close consultation

with the QCSRR

Director, the Rights

department processing

proceeds normally .

The Incident Report is

processed normally.

Initiating the RCA

process, consultation

occurs between the

Review Group (RG)**

within 5 business days

of the sentinel event.

The RG

identifies a

person to

gather facts.

The fact finder completes a

review and composes a

report that includes a

timeline of events and a list

of all who had direct or

ancillary involvement in the

sentinel event. The report is

sent to the RG.

Those involved in

the event complete

an incident report

and/or file a Rights

complaint as

appropriate.

The RG reviews the report

and determines who should

attend the RCA meeting. A

meeting is scheduled and

the report is distributed to

attendees.

The RCA meeting

convenes, led by a

designee. The

following is

accomplished:

Root Cause(s)

Determined

Action Plan(s)

Developed

The RCA action

plans are approved

by the CEO.

The RCA action plans

are monitored by the

Compliance Officer

with oversight from

the Critical Incident

Review Committee.

The QCSRR

Director

determines* if the

event qualifies as

sentinel.

Is the event a

Rights

allegation?

Yes

CMHA-CEI Peer Review Sentinel Event Process Up dated – July 2016

Yes

When appropriate

during the Rights

investigation process,

the QCSRR Director

progresses the RCA

process.

Normal Rights processing does not

include the peer review protected 1st

person accounts.

*Determination of sentinel event

qualification may involve consultation

with the Compliance Officer, Rights

Officer, and others as required.

**The Review Group is comprised of the

QCSRR Director, Medical Director,

Compliance Office, and Clinical Program

Director.

The Compliance Officer

creates a follow-up

report and consults with

those involved in the

event.

At the discretion of the

QCSRR Director and

Compliance Officer the

RCA process may be

initiated.

If RCA process

is initiated.

The Rights complaint is

processed normally .

If Rights

Complaint

If Incident

Report

Initiating the RCA

process, consultation

occurs between the

Review Group (RG)**

within 5 business days

of the sentinel event.

Within 3 business days of the

sentinel event, the QCSRR

Director sends notification to the

CEO, MSHN, and CARF that a

sentinel event has occurred.

No