Common use of Identifying and Responding to Member Incidents Clause in Contracts

Identifying and Responding to Member Incidents. The MCO shall develop and maintain an incident management system, which manages incidents occurring at the member and provider levels, in order to assure member health and safety, reduce member incident risks, and enable development of strategies to prevent future incident occurrences. The incident management system shall include policies and procedures to ensure that: The MCO IDT staff inform members/legal decision makers (and involved family and other unpaid caregivers, as appropriate) about abuse, neglect, and exploitation protections, at the initial assessment upon member enrollment or at the initial comprehensive assessment, and at each annual comprehensive assessment thereafter. Completion of this task shall be documented in the member record. MCO members/legal decision makers (and involved family and other unpaid caregivers, as appropriate) are informed of the process used to report member incidents. MCO staff and providers are trained in identifying, responding to, documenting, and reporting member incidents. Completion of training for MCO staff shall be documented in the staff member's file. Completion of training for providers shall be documented and provided upon request to DHS. Contracted providers must report member incidents to designated MCO staff no later than one (1) business day after the incident was discovered; Effective steps are taken immediately to prevent further harm to or by the affected member(s); Incidents wherein the member is a victim of a potential violation of the law are reported to local law enforcement authorities. Incidents where the member is suspected of violating the law are reported to local law enforcement, to the extent required by law; Incidents meeting criteria in Wis. Stat. §§ 46.90(4) or 55.043(1m) are reported in accordance with the applicable statute to the appropriate authority; the MCO is not responsible for or a substitute for Adult Protective Service investigations; The MCO, within three (3) calendar days of learning of the incident, notifies the member/legal decision maker of the incident, unless the member/legal decision maker reported the incident to the MCO, the MCO has within that time determined that the report was unfounded or unsubstantiated, or unless the legal decision maker is a subject of the investigation; The MCO has designated staff to conduct incident investigations who: Are not directly responsible for authorizing or providing the member's care; Have sufficient authority to obtain information from those involved and; Have clinical expertise to evaluate the adequacy of the care provided relevant to the member incident. The MCO will designate staff to provide oversight of MCO staff or the provider who shall investigate the incident in a manner consistent with the relative scope, severity and implications of any given member incident and determine and document, at a minimum, the following: The facts of the reported incident (including the date and location of occurrence), the type and extent of harm experienced by the member, any actions that were taken immediately to protect the member and to halt or ameliorate the harm; The cause(s) of the incident; Whether reasonable actions by the provider or others with responsibility for the health, safety and welfare of the member would have prevented the incident; and Interventions and/or preventative strategies which may include changes in the MCO's or provider's policies or practices to help prevent occurrence of similar incidents in the future. When warranted, an investigation of each reported member incident shall be completed within thirty (30) calendar days of the incident's discovery. If information or findings necessary for completion of the investigation cannot be obtained within 30 days for reasons beyond the MCO's control, the investigation shall be completed as promptly as possible. The MCO shall report member incident data in accordance with the Department's incident data report specifications. The report submission is due on the thirtieth day after the end of the month, or the first business day following the thirtieth day when the thirtieth day is not a business day. The report shall be submitted electronically through the Long Term Care Information Exchange System. (xxxxx://xxxxxxxxx.xxxxxxxxxxxxx.xx.xxx/ltcareIES/secureLogin.html) Within five (5) business days of completion of the investigation, the MCO shall provide notification to the member/legal decision maker (and/or the member's family, as appropriate) of the results or outcomes of the investigation. This notification shall be documented in the member record. Service Authorization

Identifying and Responding to Member Incidents. The MCO PO shall develop and maintain an incident management system, which manages incidents occurring at the member and provider levels, in order to assure member health and safety, reduce member incident risks, and enable development of strategies to prevent future incident occurrences. The incident management system shall include policies and procedures to ensure that: The MCO PO IDT staff inform members/legal decision makers (and involved family and other unpaid caregivers, as appropriate) about abuse, neglect, and exploitation protections, at the initial assessment upon member enrollment or at the initial comprehensive assessment, and at each annual comprehensive assessment thereafter. Completion of this task shall be documented in the member record. MCO PO members/legal decision makers (and involved family and other unpaid caregivers, as appropriate) are informed of the process used to report member incidents. MCO PO staff and providers are trained in identifying, responding to, documenting, and reporting member incidents. Completion of training for MCO PO staff shall be documented in the staff member's filedocumentedand provided upon request to DHS. Completion of training for providers shall be documented and provided upon request to DHSin the PO’s provider file. Contracted providers must report member incidents to designated MCO PO staff no later than one (1) business day after the incident was discovered; Effective steps are taken immediately to prevent further harm to or by the affected member(s); Incidents wherein the member is a victim of a potential violation of the law are reported to local law enforcement authorities. Incidents where the member is suspected of violating the law are reported to local law enforcement, to the extent required by law; Incidents meeting criteria in Wis. Stat. §§ 46.90(4) or 55.043(1m) are reported in accordance with the applicable statute to the appropriate authority; the MCO PO is not responsible for or a substitute for Adult Protective Service investigations; The MCOPO, within three (3) calendar days of learning of the incident, notifies the member/legal decision maker of the incident, unless the member/legal decision maker reported the incident to the MCOPO, the MCO PO has within that time determined that the report was unfounded or unsubstantiated, or unless the legal decision maker is a subject of the investigation; The MCO PO has designated staff to conduct incident investigations who: Are not directly responsible for authorizing or providing the member's care; Have sufficient authority to obtain information from those involved and; Have clinical expertise to evaluate the adequacy of the care provided relevant to the member incident. The MCO will designate staff to provide oversight of MCO staff or the provider who shall investigate the incident in a manner consistent with the relative scope, severity and implications of any given member incident and determine and document, at a minimum, the following: The facts of the reported incident (including the date and location of occurrence), the type and extent of harm experienced by the member, any actions that were taken immediately to protect the member and to halt or ameliorate the harm; The cause(s) of the incident; Whether reasonable actions by the provider or others with responsibility for the health, safety and welfare of the member would have prevented the incident; and Interventions and/or preventative strategies which may include changes in the MCO's or provider's policies or practices to help prevent occurrence of similar incidents in the future. When warranted, an investigation of each reported member incident shall be completed within thirty (30) calendar days of the incident's discovery. If information or findings necessary for completion of the investigation cannot be obtained within 30 days for reasons beyond the MCO's control, the investigation shall be completed as promptly as possible. The MCO shall report member incident data in accordance with the Department's incident data report specifications. The report submission is due on the thirtieth day after the end of the month, or the first business day following the thirtieth day when the thirtieth day is not a business day. The report shall be submitted electronically through the Long Term Care Information Exchange System. (xxxxx://xxxxxxxxx.xxxxxxxxxxxxx.xx.xxx/ltcareIES/secureLogin.html) Within five (5) business days of completion of the investigation, the MCO shall provide notification to the member/legal decision maker (and/or the member's family, as appropriate) of the results or outcomes of the investigation. This notification shall be documented in the member record. Service Authorization:

Identifying and Responding to Member Incidents. The MCO shall develop and maintain an incident management system, which manages incidents occurring at the member and provider levels, in order to assure member health and safety, reduce member incident risks, and enable development of strategies to prevent future incident occurrences. The incident management system shall include policies and procedures to ensure that: The MCO IDT staff inform members/legal decision makers (and involved family and other unpaid caregivers, as appropriate) about abuse, neglect, and exploitation protections, at the initial assessment upon member enrollment or at the initial comprehensive assessment, and at each annual comprehensive assessment thereafter. Completion of this task shall be documented in the member record. MCO members/legal decision makers (and involved family and other unpaid caregivers, as appropriate) are informed of the process used to report member incidents. MCO staff and providers are trained in identifying, responding to, documenting, and reporting member incidents. Completion of training for MCO staff shall be documented in the staff member's file. Completion of training for providers shall be documented and provided upon request to DHSin the MCO's provider file. Contracted providers must report member incidents to designated MCO staff no later than one (1) business day after the incident was discovered; Effective steps are taken immediately to prevent further harm to or by the affected member(s); Incidents wherein the member is a victim of a potential violation of the law are reported to local law enforcement authorities. Incidents where the member is suspected of violating the law are reported to local law enforcement, to the extent required by law; Incidents meeting criteria in Wis. Stat. §§ 46.90(4) or 55.043(1m) are reported in accordance with the applicable statute to the appropriate authority; the MCO is not responsible for or a substitute for Adult Protective Service investigations; The MCO, within three (3) calendar days of learning of the incident, notifies the member/legal decision maker of the incident, unless the member/legal decision maker reported the incident to the MCO, the MCO has within that time determined that the report was unfounded or unsubstantiated, or unless the legal decision maker is a subject of the investigation; The MCO has designated staff to conduct incident investigations who: Are not directly responsible for authorizing or providing the member's care; Have sufficient authority to obtain information from those involved and; Have clinical expertise to evaluate the adequacy of the care provided relevant to the member incident. The MCO will designate staff to provide oversight of MCO staff or the provider who shall investigate the incident in a manner consistent with the relative scope, severity and implications of any given member incident and determine and document, at a minimum, the following: The facts of the reported incident (including the date and location of occurrence), the type and extent of harm experienced by the member, any actions that were taken immediately to protect the member and to halt or ameliorate the harm; The cause(s) of the incident; Whether reasonable actions by the provider or others with responsibility for the health, safety and welfare of the member would have prevented the incident; and Interventions and/or preventative strategies which may include changes in the MCO's or provider's policies or practices to help prevent occurrence of similar incidents in the future. When warranted, an investigation of each reported member incident shall be completed within thirty (30) calendar days of the incident's discovery. If information or findings necessary for completion of the investigation cannot be obtained within 30 days for reasons beyond the MCO's control, the investigation shall be completed as promptly as possible. The MCO shall report member incident data in accordance with the Department's incident data report specifications. The report submission is due on the thirtieth day after the end of the month, or the first business day following the thirtieth day when the thirtieth day is not a business day. The report shall be submitted electronically through the Long Term Care Information Exchange System. (xxxxx://xxxxxxxxx.xxxxxxxxxxxxx.xx.xxx/ltcareIES/secureLogin.html) Within five (5) business days of completion of the investigation, the MCO shall provide notification to notify the member/legal decision maker (and/or the member's family, as appropriate) of the results or outcomes of the investigation. This notification Notification shall be in writing and documented in the member record. Service Authorization

Identifying and Responding to Member Incidents. The MCO shall develop and maintain an incident management system, which manages incidents occurring at the member and provider levels, in order to assure member health and safety, reduce member incident risks, and enable development of strategies to prevent future incident occurrences. The incident management system shall include policies and procedures to ensure that: The MCO IDT staff inform members/legal decision makers (and involved family and other unpaid caregivers, as appropriate) about abuse, neglect, and exploitation protections, at the initial assessment upon member enrollment or at the initial comprehensive assessment, and at each annual comprehensive assessment thereafter. Completion of this task shall be documented in the member record. MCO members/legal decision makers (and involved family and other unpaid caregivers, as appropriate) are informed of the process used to report member incidents. MCO staff and providers are trained in identifying, responding to, documenting, and reporting member incidents. Completion of training for MCO staff shall be documented in the staff member's file. Completion of training for providers shall be documented and provided upon request to DHS. Contracted providers must report member incidents to designated MCO staff no later than one (1) business day after the incident was discovered; Effective steps are taken immediately to prevent further harm to or by the affected member(s); Incidents wherein the member is a victim of a potential violation of the law are reported to local law enforcement authorities. Incidents where the member is suspected of violating the law are reported to local law enforcement, to the extent required by law; Incidents meeting criteria in Wis. Stat. §§ 46.90(4) or 55.043(1m) are reported in accordance with the applicable statute to the appropriate authority; the MCO is not responsible for or a substitute for Adult Protective Service investigations; The MCO, within three (3) calendar days of learning of the incident, notifies the member/legal decision maker of the incident, unless the member/legal decision maker reported the incident to the MCO, the MCO has within that time determined that the report was unfounded or unsubstantiated, or unless the legal decision maker is a subject of the investigation; The MCO has designated staff to conduct incident investigations who: Are not directly responsible for authorizing or providing the member's care; Have sufficient authority to obtain information from those involved and; Have clinical expertise to evaluate the adequacy of the care provided relevant to the member incident. The MCO will designate staff to provide oversight of MCO staff or the provider who shall investigate the incident in a manner consistent with the relative scope, severity and implications of any given member incident and determine and document, at a minimum, the following: The facts of the reported incident (including the date and location of occurrence), the type and extent of harm experienced by the member, any actions that were taken immediately to protect the member and to halt or ameliorate the harm; The cause(s) of the incident; Whether reasonable actions by the provider or others with responsibility for the health, safety and welfare of the member would have prevented the incident; and Interventions and/or preventative strategies which may include changes in the MCO's or provider's policies or practices to help prevent occurrence of similar incidents in the future. When warranted, an investigation of each reported member incident shall be completed within thirty (30) calendar days of the incident's discovery. If information or findings necessary for completion of the investigation cannot be obtained within 30 days for reasons beyond the MCO's control, the investigation shall be completed as promptly as possible. The MCO shall report member incident data in accordance with the Department's incident data report specifications. The report submission is due on the thirtieth day after the end of the month, or the first business day following the thirtieth day when the thirtieth day is not a business day. The report shall be submitted electronically through the Long Term Care Information Exchange System. (xxxxx://xxxxxxxxx.xxxxxxxxxxxxx.xx.xxx/ltcareIES/secureLogin.html) Within five (5) business days of completion of the investigation, the MCO shall provide notification to the member/legal decision maker (and/or the member's family, as appropriate) of the results or outcomes of the investigation. This notification shall be documented in the member record. Service AuthorizationAuthorization‌