Gila River Health Care Corporation
Gila River Health Care Corporation
PROVIDER MANUAL
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Arizona Department of Health Services

Division of Behavioral Health Services
PROVIDER MANUAL
Gila River Regional Behavioral Health Authority Edition

7.4.1 Introduction
Significant events, such as accidents, injuries, allegations of abuse, human rights violations, and deaths require careful examination and review to ensure the protection of behavioral health recipients. ADHS/DBHS, as well as other federal and state agencies, requires the prompt reporting of significant events involving persons receiving services within the public behavioral health system. The reporting of significant events to Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS), such as incidents, accidents, and deaths, serves the following purposes:

  • The collection of relevant information facilitates a comprehensive review and investigation when indicated;
  • Compliance with notification requirements to the Centers for Medicare and Medicaid Services (CMS), Arizona Health Care Cost Containment System (AHCCCS), the Arizona Center for Disability Law, and ADHS/Office of Behavioral Health Licensure (OBHL) as applicable; and
  • The trending and analysis of significant events can identify opportunities for behavioral health system improvements.

The intent of this section is to identify reporting requirements for behavioral health providers following an incident, accident, or death involving a behavioral health recipient. In addition, T/RBHAs may require subcontracted providers to submit a written summary of their review of deaths of adult Non-Seriously Mentally Ill (SMI) behavioral health recipients. Behavioral health providers must be aware of what constitutes an event that requires reporting (by either the T/RBHA or behavioral health providers) to:

  • CMS;
  • AHCCCS;
  • ADHS/DBHS;
  • The Arizona Center for Disability Law;
  • ADHS/OBHL.

Behavioral health providers must know what information is to be reported, including any applicable forms and/or reports; and where the requisite information must be sent within the agencies identified above.

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7.4.2 References
The following citations can serve as additional resources for this content area:

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7.4.3 Scope
To whom does this apply?

All persons receiving behavioral health services.

7.4.4 Did you know…?

  • All deaths, regardless of whether the enrolled recipient is a child, adult with Serious Mental Illness or adult without a Serious Mental Illness, are reviewed by ADHS/DBHS Medical Director or designee, and selected cases are referred to the ADHS/DBHS Mortality and Morbidity Committee for further review and potential action, in accordance with ADHS/DBHS established quality assurance process.
     
  • OBHL licensed Level I behavioral health facilities are required to report any serious occurrence that occurs as a result of a seclusion and restraint event, in accordance with Section 7.3, Seclusion and Restraint Reporting.
  • Upon recognition of abuse, neglect or exploitation of an incapacitated person, behavioral health providers must immediately report the allegation to the appropriate authorities (i.e., police or protective services worker) in accordance with A.R.S. 46-454. The oral report must be followed up by a written report within 48 hours. See Section 7.6, Duty to Report Abuse, Neglect or Exploitation.
  • Each state has a designated protection and advocacy system. In Arizona, the Arizona Center for Disability Law serves as the designated protection and advocacy agency.

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7.4.5 Definitions
Abuse

Behavioral Health Recipient

Enrolled Person

Exploitation

Incapacity

Incident or Accident

Level I Facility

Neglect

Prevention Activity

Serious Injury

Serious Occurrence

7.4.6 Objectives
To identify reporting requirements for behavioral health providers following:

  • An incident, accident or death of any behavioral health recipient;
  • An incident, accident, or death of any behavioral health recipient during a prevention activity, regardless of his or her enrollment status; and
  • An allegation of abuse of any behavioral health recipient determined have a Serious Mental Illness.

To identify procedures for behavioral health providers in submitting a summary of their review of deaths of adult Non-SMI behavioral health recipients.

7.4.7 Procedures

7.4.7-A. Reporting incidents, accidents, and deaths to the T/RBHA
Behavioral health providers must report any incident or accident as defined by this section of an enrolled behavioral health recipient to the T/RBHA within 48 hours.

Behavioral health providers are to report any incidents or accidents involving a Gila River RBHA enrolled member to the Gila River RBHA Manager of Quality Management/Utilization Management. Reports may be faxed to (520) 550-6040 or mailed to the following:

Gila River RBHA/New Beginnings Building
ATT: Manager of QM/UM
Hu Hu Kam Memorial Hospital
P.O. Box 38
Sacaton, AZ 85147

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7.4.7-B. Reporting incidents, accidents, and deaths during prevention activities

Behavioral health providers are required to report to the T/RBHA any incident, accident or death of a behavioral health recipient participating in the T/RBHA or provider sponsored prevention activity, as defined in this section, regardless of his or her enrollment status with the T/RBHA within 48 hours.

PM Form 7.4.1, Incident/Accident/Death Report Form must be used for reporting incidents, accidents and deaths of enrolled behavioral health recipients; and incidents, accidents and deaths occurring during prevention activities.

Reports may be faxed to (520) 550-6040 or mailed to the following:

Gila River RBHA/New Beginnings Building
ATT: Manager of QM/UM
Hu Hu Kam Memorial Hospital
P.O. Box 38
Sacaton, AZ 85147

7.4.7-C. Review of Deaths to the T/RBHA
T/RBHAs may require behavioral health providers prepare and submit a written summary of their review of deaths only for adult, Non-SMI behavioral health recipients using the ADHS/DBHS Mortality Review Form, contained in the Performance Improvement Specification Manual Section XVII. If Gila River RBHA makes such a request, the behavioral health provider shall submit the completed information within thirty (30) calendar days of the request.

7.4.7-D. Reporting allegations of abuse towards persons determined to have a Serious Mental Illness
Allegations of abuse concerning persons determined to have a Serious Mental Illness must be reported within 48 hours to the T/RBHA. PM Form 7.4.1 Incident/Accident/Deaths Report Form must be used to report occurrences of abuse to the T/RBHA.

Behavioral health providers are to report allegations of abuse towards persons determined to have a serious mental illness to the Gila River RBHA Manager of Quality Management/Utilization Management. Reports may be faxed to (520) 550-6040 or mailed to the following:

Gila River RBHA/New Beginnings Building
ATT: Manager of QM/UM
Hu Hu Kam Memorial Hospital
P.O. Box 38
Sacaton, AZ 85147

7.4.7-E. Reporting incidents, accidents and deaths to the Office of Behavioral Health Licensure

  • Behavioral health providers licensed by OBHL must provide notification to OBHL involving any incident or accident as defined on PM Form 7.4.1.

Behavioral health providers must orally report the above referenced events to ADHS/OBHL within one working day of knowledge of the event (contact OBHL at 602-364-2595). The oral report must be followed up with a written incident report within 5 working days. Behavioral health providers must maintain a copy of the written incident report on the premises or at the administrative office for at least 12 months after the date of the written incident report.

Community Service Agencies (CSAs) which are not licensed with OBHL, are not required to report any incidents, accidents or deaths to ADHS/OBHL that occur during a T/RBHA or provider sponsored prevention activity.

7.4.7-F. Reporting deaths and serious occurrences in OBHL Level I Facilities
This subsection is applicable to Title XIX certified/OBHL licensed Level I behavioral health facilities that provide inpatient psychiatric services to persons under the age of 21.

Reporting serious occurrences of behavioral health recipients:
Title XIX certified/OBHL licensed Level I behavioral health facilities that provide inpatient psychiatric services to persons under the age of 21 are required to report any serious occurrences (see definition) involving a behavioral health recipient to:

  • AHCCCS;
  • The Arizona Center for Disability Law; and
  • CMS Regional Office (for deaths only).

What are the timeframes?
Any serious occurrence involving a behavioral health recipient in a Level I facility must be reported to AHCCCS, the Arizona Center for Disability Law, and the CMS Regional Office (for deaths only) no later than close of business of the next business day following the serious occurrence.

Where must the report be sent?
For serious occurrence reporting, send information to:

  • AHCCCS
    FAX Number (602) 417-4855-Attention DHCM Behavioral Health Administrator
  • The Arizona Center for Disability Law
    FAX Number (602) 274-6779-Attention Investigator
  • CMS Regional Office (to report a death only)
    FAX Number (415) 744-2692-Attention Survey & Certification Coordinator

Other considerations
Specific documentation requirements apply to ADHS/OBHL licensed behavioral health provider records. Please see Section 4.2, Behavioral Health Medical Record Standards.

In the case of a minor (person under the age of 18), the Level I facility must also notify the person’s parent(s) or legal guardian(s) as soon as possible, but no later than 24 hours from the serious occurrence.

Note that these reporting requirements pertain only to serious occurrences (see definition). Reports of non-serious occurrences and other events must not be made to AHCCCS, the Arizona Center for Disability Law, or CMS.

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7.4 Reporting of Incidents, Accidents and Deaths
Last Revised: 1/15/2010
Effective Date: 1/15/2010

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