Incident Management Policy and Procedures

Incident Management Policy and Procedures

 

Contents

  1. Policy. 2
  2. Outcomes. 2
  3. Definitions. 2
  4. Related Policies / Documents. 3
  5. Procedures. 3
  6. Identifying Incidents. 3
  7. For all incidents. 3
  8. Incident Investigations. 4
  9. Outcomes. 4
  10. Follow-Up / Review.. 4
  11. When a Participant incident / injury occurs. 4
  12. Mandatory reporting of suspected incidents of risk of harm to a participant / client 5
  13. Policy. 5
  14. Outcome. 5
  15. Procedures. 5

Group A      Participants being funded by NDIS.. 6

Group B      All children aged from birth to 18 years regardless of funding source. 6

Group C      Disability clients aged 16 to 65 not being funded under NDIS.. 7

Group D      Older clients aged 65 and over 7

Workers. 7

  1. Training Workers on Incident Management 8
  2. Appendix A: NDIS Processes for Reporting Incidents. 8

STEP 1. Notify the NDIS Commission. 8

STEP 2: Submit a 5 Day Form.. 9

STEP 3. Submit a final report, if required. 9

 


 

 

1.    Policy

CTC CARE will promote the health, safety, welfare and well-being of its clients and meet its professional and legal responsibilities by ensuring any incidents are appropriately:

  • identified and recorded
  • assessed to determine corrective and / or harm minimisation strategies
  • investigated where necessary
  • followed up in a timely manner and to ensure satisfactory outcomes are achieved
  • considered against legislative / funding body requirements / guidelines (including the NDIS Quality and Safeguards Commission: Incident Management Systems) and acted upon / reported as required
  • shared where appropriate to assist with quality improvement.

 

2.    Outcomes

  • Risks will be identified and managed to eliminate or minimise any adverse event
  • The impact of any incident will be minimised
  • Clients / other stakeholders will be satisfied with the outcome of the management of risks and incidents
  • Involved Workers are aware and accepting of the outcome of the management of risks and incidents 
  • There will be minimal reoccurrence of incidents
  • CTC CARE Director or Business Owner will be aware of risks and incidents and the actions taken to manage these events

 

3.    Definitions

 

Incident           event or situation that could have resulted in harm to an individual or to the business. This includes, but is not limited to:

  • Injury and / or near-miss to participant
  • Injury and / or near-miss to workers
  • Acts by a person with disability that did or may have caused serious harm
  • Complaint or negative feedback about the service
  • Actual or suspected abuse of participant / others
  • Breach of privacy / other participant rights eg restrictive practice
  • Less than expected therapeutic outcome
  • Damage to equipment / goods
  • Breach of statutory obligations

Note: NDIS Definition

“An incident is defined as an act, omission, event or circumstance. It may mean any of the following:

  • Acts, omissions, events or circumstances that occur in connection with providing NDIS supports or services to a person with disability and have, or could have, caused harm to the person with disability
  • Acts by a person with disability that occur in connection with providing NDIS supports or services to the person with disability and which have caused serious harm, or a risk of serious harm, to another person
  • Reportable incidents that have or are alleged to have occurred in connection with providing NDIS supports or services to a person with disability”

NDIS Commission Incident Management Systems: Detailed Guidance for Registered NDIS Providers June 2019, p3

Accident          event or situation that actually resulted in harm to an individual or damage

to equipment

Risk                 something that could potentially lead to an incident or accident

 

For the purpose of this policy, incidents and accidents will be referred to as “incident” for ease of reading.

 

4.    Related Policies / Documents

  • Feedback and Complaints Management Policy
  • Safe Management and Environment Policy
  • Risk Management Policy
  • Risk Management Register
  • Service Delivery Model
  • Incident and Complaint Report
  • Incident Investigation Form

 

5.    Procedures

See also:

  • Section 6 if incident relates to suspected abuse
  • Feedback and Complaints Management Policy if the incident is feedback / a complaint)

 

a.    Identifying Incidents

While some incidents are obvious (eg a client fall) it is also important to understand that not all incidents may be so readily identified. Section 3.1 of the NDIS Commission Incident Management Systems: Detailed Guidance for Registered NDIS Providers June 2019 provides guidance to XXX and its’ staff to consider potential indicators and signs associated with particular types of incidents. While it is acknowledged that this is not an exhaustive list, staff will be educated to assist them with better identifying incidents or potential incidents.

 

b.    For all incidents

  • Director / management is to be notified of all incidents
  • An Incident and Complaint Report form is to be completed within 48 hours of the incident . The report must include all necessary factual details, immediate actions that have been taken, any identified / planned follow-up actions, any reports made to other bodies
  • The incident is recorded in the XXX Incidents and Complaints Register by the Director / senior allocated staff member. Access to the register and any completed forms must be limited to senior staff only.
  • Actions are to include as a minimum
    • Providing support to the affected person/s 
    • Consideration by Directors / Management if the incident is reportable and if police / other agencies should be involved, and actions then taken as appropriate
    • When, how and with whom follow-up will occur
    • Risk assessment of the incident, including seeking feedback from involved parties e.g. Participant, workers
    • Evaluation / review at the conclusion of the incident to ensure involved parties are satisfied with the outcome
    • Consideration of what people / process / policy changes could be made to improve XXX 's systems (refer to ' 5d. Outcomes' below).

 

c.    Incident Investigations

  • If required, a formal incident investigation will be conducted (use the Incident Investigation Form) to explore in more detail why an incident occurred and if any steps are required to prevent it occurring again. As a minimum, incidents requiring investigation include:
    • Any 'Notifiable' incident (refer to Appendices A and B for what needs to be reported, to whom and how)
    • Any mandatory report made (see Section 6 below)
    • Any incident that could lead to potential litigation.

Note: If police are involved in the incident, no internal investigation is to commence until the police investigations are complete

  • The Governing body is to be informed as soon as practicable of any incident investigations and their outcomes

 

d.    Outcomes

  • Outcomes of formal or informal assessments / investigation could include:
    • Further training of staff / others involved
    • Reviewing and enhancing policies and / or procedures
    • Changes to the environment / delivery mode for support services
    • Participant (and / or his/her family) and Provider agree to accept the risks inherent in support delivery to achieve goals

 

e.    Follow-Up / Review

  • Actions will be monitored by the Director and updates on progress will be added to the register until the incident is satisfactorily concluded
  • The Governing body will review the management of all incidents
  • Incident reports and all related documents are to be kept for 7 years.

 

f.     When a Participant incident / injury occurs

  • Respond to immediate needs and re-establish a safe environment. Make sure participant, worker and any others present are safe
  • If required, call emergency services to assist, seek medical attention, commence first aid
  • Contact the appropriate emergency contact or 'significant other' (eg parent / spouse / son / guardian) as soon as practicable
  • Determine what support the participant and / or their family require and how this can be best delivered. This is to include asking them if they want the support of an advocate
  • Consult with the participant and / or their family on how to satisfactorily resolve the issue and what could have been done to prevent it occurring
  • Keep the participant informed of progress on the incident
  • If a participant / client is involved and receives funding from a government body (e.g. NDIS*, icare, DVA), the Director will review the requirements and complete the required reporting i.e. Notifiable Incidents (refer to Appendices A & B)
  • If the incident could lead to any potential litigation, XXX 's professional liability insurer must be informed.

 

6.    Mandatory reporting of suspected incidents of risk of harm to a participant / client

 

Policy

CTC CARE will promote the health, safety, welfare and well-being of its participants / clients and meet its professional and legal responsibilities by ensuring any suspected abuse is appropriately assessed and considered against set guidelines and reported as required.

 

g.    Outcome

  • XXX fulfils its statutory obligations under the relevant insert state / territory legislation.

The following website is a great resource for explaining what is required in each jurisdiction. It also has key contacts per state / territory and guidelines to assist you / your staff. It may be worthwhile to attach extracts from either this or the relevant government departments in your policy or as Appendixes

https://aifs.gov.au/cfca/publications/mandatory-reporting-child-abuse-and-neglect

  • CTC CARE will feel assured participants identified as "at risk" will receive assistance through the authorities responsible
  • CTC CARE staff will feel supported by management through the mandatory reporting process.

 

h.    Procedures

For all suspected incidents of risk of harm the following steps are to be taken. Any specific requirements for children, adults or aged clients are listed below these, as are the documentation requirements.

 

Staff member who suspects a person (child, adult, aged person) may be at significant risk of harm is to determine if a report may have been made by other members of the support team (e.g. his / her Case Manager, NDIS Support Coordinator). If written evidence of the report having been made is provided, there is no further requirement for a report to be made. If no report has been made the following steps are to be followed:

    1. Allied Health Professional (AHP) is to make observations regarding the participant / client to collect as much information as possible about the situation - if safe to do so.
    2. Record information in the participant / client notes.
    3. As soon as practicably possible, but within at least 24 hours
  1. review the situation against the appropriate legislation / guides (as per Groups A-D below).
  2. complete CTC CARE Incident and Complaint Form. Where possible, this is to include additional details.
  1. The AHP is to assess the situation using the appropriate guidance material (as per Groups A-D below) and / or seeking assistance from the relevant authority or YYYY Police.  
  2. If a decision is made that mandatory reporting is required, the Director must be contacted. He / she will assist with the reporting process.
  3. If after reference to the relevant guide / policy the matter is considered urgent it will be reported to the appropriate service by the required method.
  4. If the risk is considered non-imminent, an online report will be completed
  5. CTC CARE will assist with any investigation or action undertaken by the department or other authorised bodies as a result of the report
  6. CTC CARE will monitor progress and add actions / development to the completed incident form until the matter is resolved or closed. Reporting and monitoring shall be as per the Incidents and Complaints management system

 

CTC CARE as identified four groups (A-D) where various requirements will need to be met / followed.

 

Group A                    Participants being funded by NDIS

 

NDIS require to be reported:

“Reportable incidents are serious incidents or alleged incidents which result in harm to an NDIS participant and occur in connection with NDIS supports and services. Specific types of reportable incidents include:

  • The death of a person with disability.
  • Serious injury of a person with disability.
  • Abuse or neglect of a person with disability.
  • Unlawful sexual or physical contact with, or assault of, a person with disability (excluding, in the case of unlawful physical assault, contact with, and impact on, the person that is negligible).
  • Sexual misconduct committed against, or in the presence of, a person with disability, including grooming of the person for sexual activity.
  • The use of a restrictive practice in relation to a person with disability, other than where the use is in accordance with an authorisation (however described) of a State or Territory in relation to the person or a behaviour support plan for the person.”

NDIS Commission Incident Management Systems: Detailed Guidance for Registered NDIS Providers June 2019, p4

 

The procedures for NDIS Incident Management are outlined in Appendix A. Also refer to Group C below as these resources are also useful for NDIS participants eg for access to advocacy services. If it is a child you also need to report as per Group B below.

 

Group B          All children aged from birth to 18 years regardless of funding source

 

Specific requirements for children

  1. If there are concerns the child's health or life is at imminent risk, contact the police by calling 000.

In other situations the following steps are to be taken:

  1. Assess the situation using the insert relative state / territory guidance e.g. NSW online Mandatory Reporter Guide which provides a decision tree on whether or not a report to the Child Protection Helpline is appropriate.
  2. If the matter is considered urgent (using the Mandatory Reporting Guide) submit a report by phone to the Child Protection Helpline on 132 111.
  3. If the risk is considered non-imminent an electronic report is to be completed using the eReporting System.

 

Group C            Disability clients aged 16 to 65 not being funded under NDIS

 

For non-government funded clients with a disability aged 16-65

Advice is to be sought from:

  • the National Disability Abuse and Neglect Hotline can receive complaints and provide access to advocacy – phone 1800 880 052

https://www.jobaccess.gov.au/people-with-disability/do-you-need-report-abuse-or-neglect-people-with-disability

  • insert State/Territory names / details Police Force can investigate all crimes, including assault, theft and fraud
  • insert State/Territory names / details Ombudsman phone ,

 

Assistance for the participant to access an advocate as required can also be by  referral to appropriate service such as, Disability Advocacy NSW ; Advocacy Queensland Incorporated; Advocacy Tasmania; Disability Rights Advocacy Service Inc South Australia; Advocacy Western Australia; ADACAS ACT; Disability Advocacy Service NT

 

Group D                    Older clients aged 65 and over

Background

Each state and territory provides information about abuse and abuse prevention, as well as advocacy, useful contacts and options for getting help. My Aged Care includes elder abuse contacts / links for all states and territories.

An example of the excellent information available is this resource from the SA Aged Rights Advocacy Service (ARAS) Protocol For Responding To Abuse Of Older People Living At Home In The Community 2011. http://www.sa.agedrights.asn.au/resources/publications

It provides a very useful flow chart outlining actions to take depending on level and immediacy of risk, capacity, consent. It is also has case studies and is a great resource for training.

There is also guidance if the abuse happens in residential care facilities

https://agedcare.health.gov.au/ensuring-quality/aged-care-quality-and-compliance/guide-for-reporting-reportable-assaults

 

Specific requirements for clients aged over 65

  1. If you witness, are told about or suspect elder abuse is occurring, seek advice from either
    1. The national 1800 ELDERHelp (1800 353 374) line (freecall). They provide information on how you or the person involved can get help, support and get referrals.
    2. The identified situation will be assessed using guidance available from the insert state / territory service
  2. Follow guidance as per your state or territory resources

 

 

 

Workers

Also note, If a worker is harmed you will need to report to YYY SafeWork - insert appropriate authority and review what needs to be reported and when – links can be found here https://www.safeworkaustralia.gov.au/

 

7.    Training Workers on Incident Management

 

All staff will receive initial and refresher training on Incident Management, including mandatory reporting. Refer to Annual Training Plan.

 

8.    Appendix A: NDIS Processes for Reporting Incidents

 

In the box below is an extract from the NDIS Quality and Safeguards Commission. It outlines the reporting requirements to the NDIS including timeframes and required forms.

 

Extracted 6 Feb 2020

https://www.ndiscommission.gov.au/providers/incident-management-and-reportable-incidents

 

How to notify the NDIS Commission of a Reportable Incident from 1 July 2019

 

There are key steps for registered NDIS providers to notify the NDIS Commission about reportable incidents. These are outlined below.

From 1 July 2019 registered NDIS Providers in ACT, SA, NSW, NT, QLD, TAS and VIC should use the NDIS Commission Portal ‘My Reportable Incidents’ page to notify and manage all reportable incidents.

 

STEP 1. Notify the NDIS Commission

·         The Immediate Notification Form must be submitted via the NDIS Commission Portal within 24 hours of key personnel becoming aware of a reportable incident or allegation.

·         The Immediate Notification Form includes a number of sections and questions, concerning details of the reportable incident, actions taken in response to the incident and the individuals involved in the incident.

·         An exception to this rule is notifying the NDIS Commission of the use of a restrictive practice that is unauthorised or not in accordance with a behavior support plan. In these instances, the provider must notify the NDIS Commission within five business days of being made aware of the incident. If however, the incident has resulted in harm to a person with disability, it must be reported within 24 hours.

·         To notify the NDIS Commission of an incident the authorised ‘Notifier’ or ‘Approver’ needs to login to the NDIS Commission Portal and select ‘My Reportable Incidents’ tile at the top of the screen. From here, you will be able to complete an Immediate Notification Form.

·         The NDIS Commission suggests the ‘Authorised Reportable Incidents Approver’ is the person you want to have the authority to review and be responsible for submission to the NDIS Commission. This could be the person specified in your incident management system who is responsible for reporting incidents to the NDIS Commission. The authorised ‘Approver’ will have the ability to submit new Reportable Incidents and view previous Reportable Incidents submitted by their organisation.

·         The NDIS Commission suggests the ‘Authorised Reportable Incidents Notifier’ is a supporting team member who can assist the ‘Authorised Reportable Incidents Approver’ to collate and report the required information. The authorised ‘Notifier’ will have the ability to create new Reportable Incident notifications to be saved as a draft for review and submission by the authorised ‘Approver’. The authorised ‘Notifier’ will need to inform the authorised ‘Approver’ that the Incident is awaiting their review and submission. The ‘Notifier’ can also view past Reportable Incidents they have created through the page.

 

STEP 2: Submit a 5 Day Form

·         The 5 Day form must be submitted via the ‘My Reportable Incidents’ portal within five business days of key personnel becoming aware of a reportable Incident. This provides additional information and actions taken by the NDIS registered provider.

·         The five-day form is also to be used for incidents involving the unauthorised use of a restrictive practice, other than those resulting in immediate harm of a person with disability.

 

STEP 3. Submit a final report, if required

·         You may be required to provide a final report. When this is the case, the NDIS Commission will notify you via email and tell you the date this is due.

·         If you are required to submit a final report, you will have access to the final report fields on the NDIS Commission Portal for that incident.

There are key considerations for registered NDIS providers. In all cases, providers must assess:

·         The impact on the NDIS participant.

·         Whether the incident could have been prevented.

·         How the incident was managed and resolved.

·         What, if any, changes will prevent further similar events occurring.

·         Whether other persons or bodies need to be notified.

 

Where appropriate, the NDIS Commission may require a provider to take remedial measures. The NDIS Commission may work with the provider to implement these measures, and monitor progress. Remedial measures may include, but are not limited to, additional staff training and development or improved services to support NDIS participants and updating policies and procedures.

For further information including hints and tips, please refer to the Reportable Incidents Frequently Asked Questions.”

 

If you are unable to login to make a report, got to website referred to at the top of this box and follow the outlined steps.

 

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