(April 2008; Updated June 2008) New Update: July 2009
Information Bulletin 08-04
NH-128
BCH-44
Hospitals with Swing Beds-51
This bulletin has been updated to include hospitals with swing beds, which also must report via the new MDH web site. This bulletin has been updated to include 2009 legislative changes in language to Minnesota Statutes, section 626.557 which allows providers to submit an electronic copy (fax) of the MDH web site incident reporting form to the Common Entry Point. All changes are underlined.
Major Change in Reporting Process - Do Not Disregard
EFFECTIVE APRIL 14, 2008 - Required Electronic Notification to MDH Via the Web for Reporting Incidents Within 24 Hours of the Incident’s Discovery, as required at 42 CFR 483.13(c)(2) and for timely submission of the facility’s investigative reports as required at 42 CFR 483.13 c(4)
Purpose:
The purpose of this informational bulletin is to notify federally certified Skilled Nursing Facilities/Nursing Facilities (SNF/NFs), Skilled Nursing Facilities (SNFs), Nursing Facilities (NFs), and hospitals with swing beds that the Centers for Medicare and Medicaid Services (CMS) Region 5 Office has directed the State Agency (MDH) to work with the above facilities to ensure that they are in compliance with the requirements at 42 CFR 483.13 related to reporting incidents to MDH. The incidents, which are required to be reported, are abuse, neglect, mistreatment, misappropriation of resident property, and injuries of unknown origin. The regulations require that facilities report incidents to MDH within 24 hours and submit the facility’s investigative reports within five working days of the incident. In addition, the MDH is to ensure that the facilities understand the federal definitions of a reportable incident and report accordingly.
Background:
On December 11, 2007, Region 5 CMS issued notice to MDH that federally certified nursing homes were not in compliance with federal regulations 483.13(c) (2) and (4). The regulation at (c)(2) states:
“The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).”
“Immediately” means as soon as possible, but not more than 24 hours after discovery of the incident (Appendix PP of the State Operations Manual, Transmittal 22, 12-15-06).
Currently, SNF/NFs, SNFs, and NFs and hospitals with swing beds are not in compliance because under the reporting mechanism via the Common Entry Point (CEP), the facilities have 24 hours to report the allegation to the CEP, and the CEP has two working days to forward reported incidents to MDH. Therefore, the facilities are not meeting the requirements of the federal regulations at 42 CFR 483.13 (c) (2), related to reporting incidents to MDH within 24 hours.
The regulation at 42 CFR 483.13 (c)(4) states:
“The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate action must be taken.”
Facilities are not in compliance with (c) (4) because, under the current mechanism, facilities have not submitted their investigative reports to MDH unless MDH requested the information. This does not meet the federal requirements of submitting an investigative report and does not meet the federal time line for doing so. Therefore, MDH will no longer send letters to the facility requesting more information. In order for the facility to be in compliance, an investigative report must be submitted electronically, within the required time line of five working days.
CMS also stated that there are differences between state and federal definitions of reportable incidents and expressed concern that some federally reportable incidents may not be reported because the state’s reporting law (MN Statutes 626.557) does not require the incidents to be reported. For example, resident to resident abuse is not reportable under the state’s reporting law unless the resident sustains serious injury. However, the federal regulation does not specify the level of harm but rather refers to “physical harm, pain or mental anguish.”
To Comply
The facility must be able to assure MDH that it reported all reportable incidents.
The facility must be able to assure MDH that the facility investigation is reported within five working days of the incident.
In accordance with federal requirements, the following definitions delineate what is to be reported to MDH within 24 hours of the incident’s discovery:
- Mistreatment (no definition provided at this time)
- Neglect - Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness (42 C.F.R. 488.301)
- Abuse - The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish (42 C.F.R 488.301)
- Injuries of unknown source - An injury should be classified as an “injury of unknown source” when both of the following conditions are met:
- Misappropriation of resident property - The deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident’s belongings or money without the resident’s consent (42 C.F.R. 488.301)
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- The source of the injury was not observed by any person or the source of the injury could not be explained by the resident: and,
- The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.
Reporting Incidents to MDH
Facilities will report incidents to MDH via a secure web site. This is a two-step process, initially reporting the incident and then submitting an investigative report. When the initial report related to the incident is made, a tracking number will automatically be assigned to the incident. Upon submission of the initial report to MDH, the facility will receive a message, including the incident tracking number, confirming receipt of the report and informing the facility that an investigative report must be submitted to MDH. SAVE THIS NOTICE - it is the facility’s verification of compliance with the requirement to report and may be requested at the time of the facility’s next survey. In addition, in order to comply with MN Statutes 626.557 related to reporting incidents, the facility must call the CEP. Two days after the facility files the initial incident report via the MDH web site, a message will be sent electronically reminding the facility to submit the investigative report.
Effective August 1, 2009 an exception is added to the requirement for an oral Common Entry Point report made for a boarding care home that is licensed under Minnesota Statutes, sections 144.50 to 144.58 and certified under Title 19 of the Social Security Act, a nursing home that is licensed under Minnesota Statutes, section 144.02 and certified under Title 18 and Title 19 of the Social Security Act, a hospital that is licensed under Minnesota Statutes, sections 144.50 to 144.58 and has swing beds certified under CFR, title 42, section 482.66 (incident reports required for swing bed patients only). As a result of the 2009 legislation, these providers are allowed to submit an electronic (fax) copy of the MDH web-based incident reporting form to the Common Entry Point (CEP).
NOTE: IN ORDER FOR THE COMMON ENTRY POINT TO ACCEPT FAXED COPIES OF THE MDH INCIDENT REPORTING FORM IN REPLACEMENT OF ORAL (TELEPHONE) REPORTING, PROVIDERS MUST COMPLETE ALL AVAILABLE INFORMATION AS REQUESTED ON THE FORM. MDH WILL MAKE ANY ADDITIONAL CHANGES TO THE CURRENT INCIDENT REPORTING FORM BY AN ANTICIPATED DATE OF OCTOBER 1, 2009. PROVIDERS WILL BE NOTIFIED ELECTRONICALLY OF ANY CHANGES TO THE CURRENT INCIDENT REPORTING FORM AND/OR WEB SITE PRIOR TO THIS DATE. AFFECTED PROVIDERS SHOULD CONTACT THEIR IDENTIFIED COMMON ENTRY POINT CONTACTS TO SECURE FAX PHONE NUMBERS IF THE FAXED REPORT OPTION IS TO BE UTILIZED.
FOR ADDITIONAL INFORMATION ON 2009 LEGISLATIVE CHANGES TO THE CEP REPORTING SYSTEM AND THE VULNERABLE ADULTS ACT PLEASE REFER TO DHS BULLETIN No. 09-25-09 NURSING FACILITY POLICY CHANGES IN 2009 LEGISLATION (July 17, 2009).
The second step involves electronically submitting the facility’s investigative report to MDH. Within five working days (Monday through Friday, excluding holidays) of the incident, complete the internal investigation, enter the information onto the web site, and submit it to MDH. If the facility fails to send an investigative report to MDH, a reminder will be sent electronically. Once an investigative report has been submitted, the facility will receive an electronic notification. A copy of the electronic notification should be retained for future reference.
Notification to MDH via the web at:
https://www.health.state.mn.us/divs/pqc/cep_reporting_login.cfm
Facilities may also access the incident reporting log from the OHFC home page at
http://www.health.state.mn.us/divs/fpc/ohfcinfo/contohfc.htm
and then click on “Nursing Home Incident Reporting.”
Prior to the effective date of April 14, 2008, MDH will mail information to each SNF/NF, SNF, and NF. In addition, prior to the effective date of June 16, 2008, MDH will mail information to each hospital with swing beds. This information will include the facility’s user identification number, password, and instructions for filing an initial report and investigative report via the electronic system. After logging in, the facility may change the password. Please remember that the new password must contain only letters or numbers.
In addition, please modify the facility’s policy and procedure for reporting incidents to reflect these changes.
For questions about this bulletin, please call our Intake section at 651-201-4200.