Critical Incident Reporting and Analysis System (CIRAS) Manual

Purpose of CIRAS

The Division of Developmental Disabilities (DDD) has developed the Critical Incident Reporting and Analysis System (CIRAS) to capture electronic reports from providers and Independent Service Coordination (ISC) agencies for critical incidents involving individuals with developmental disabilities in the State's Medicaid Waiver programs. The types of incidents to be reported are listed and defined within this manual.

The reported information will be used to:

  • Inform ISC agencies of potential issues involving the participants whose general health and well-being the ISCs are monitoring,
  • Ensure incidents are addressed appropriately, and
  • Analyze potential systemic issues and take steps to enhance overall system quality.

CIRAS is not a reporting system for alleged incidents of abuse, neglect, or exploitation. Providers should continue to report alleged cases of abuse, neglect or exploitation to the Department of Human Services' Office of the Inspector General (OIG), Department of Children and Family Services (DCFS), Department on Aging / Adult Protective Services (APS), and/or Department of Public Health as appropriate and required in accordance with the type of service involved.

CIRAS: Overview

When a community provider is aware that an individual has experienced a critical incident as defined below, the community provider will use CIRAS to report the incident to the DDD. The CIRAS system will automatically notify the appropriate ISC agency identified in the report. The ISC agency will perform the appropriate follow-up, enter a summary in CIRAS of the follow-up actions taken, and if necessary, notify the Division of unresolved incidents as indicated in the Problem and Conflict Resolution Protocol. For some types of incidents, the Division may become directly involved in addressing the incident.

In addition to entering follow up for CIRAS incidents submitted by community providers, the ISC agencies should create CIRAS reports for incidents they become aware of that have not been reported. Unresolved issues with CIRAS incidents should be reported to the DDD per the Problem and Conflict Resolution Protocol.

CIRAS will compile data based on the CIRAS incidents reported. The DDD will have the ability to review all submitted CIRAS data while the ISC agencies will be able to review data relevant to them. Community providers will be able to review the CIRAS data relating to incidents they have reported

Critical Incidents Defined

Critical Incidents are the alleged, suspected, or actual occurrence of an incident when there is reason to believe the health or safety of an individual may be adversely affected or an individual may be placed at a reasonable risk of harm. CIRAS reports do not include abuse, neglect, or exploitation incidents. These allegations should continue to be reported to the appropriate agency; Department of Human Services' Office of the Inspector General (OIG), Department of Children and Family Services (DCFS), Department on Aging / Adult Protective Services (APS), and/or Department of Public Health (IDPH).

Critical incidents are defined below.

911 Call: All calls to 911 for emergency personnel response that do not fit into any other category. Calls for emergency response that are initiated by persons receiving supports from the provider agency should be included here, even if they are later determined to be inappropriate. A description of the reason for the call should be included in the narrative. Calls to 911 for medical emergencies should be reported as "Medical emergency".

Deaths: Deaths of participants who receive services while living in their own or family's home. Deaths of participants residing in residential settings are not reported as part of this data process since they are reported to OIG as per Rule 50.

Known injury: A known injury is any injury from a known cause that is not considered abuse or neglect and that requires immobilization, casting, five or more sutures or the equivalent, second or third degree burns, dental injuries, eye injuries, or any injury that prohibits the individual from participating in routine daily tasks for more than two consecutive days. In some cases, an injury may not be immediately recognized as requiring reporting. A known injury becomes reportable at the point where there is recognition that it fits this definition.

Law enforcement: Any incident that results in the individual being charged, incarcerated, or arrested. Calls to 911 for assistance that do not result in charges, arrest, or incarceration are not required to be reported in this category.

Medical emergency: Any incident where emergency medical intervention is required to save an individual's life (e.g., Heimlich maneuver, cardiopulmonary resuscitation, intravenous therapy for dehydration). Calls for 911 medical assistance should be reported as "medical emergency" even if the cause is other than the examples provided. A 911 call is not required for an issue to be reported as a "medical emergency". Issues that are resolved through intervention of agency staff that would have likely resulted in death if the action had not occurred should be reported.

Missing individual: An incident that is not attributed to neglect, as define by Rule 50, and the individual cannot be located for a period of time longer than specified in the personal plan; the individual cannot be located after actions specified in the personal plan are taken; the individual cannot be located in a search of the immediate surrounding area; circumstances indicate that the individual may be in immediate jeopardy; or law enforcement has been called to assist in the search for the individual.

Peer-to-peer acts: Acts committed by one individual against one or more individuals when there is physical abuse with intent to harm; verbal abuse with intent to intimidate, harass, or humiliate resulting in emotional distress or maladaptive behavior; any sexual abuse; any exploitation; or intentional misappropriation of property. In some cases, such incidents may need to be reported to OIG as potential staff neglect or exploitation, rather than reported in CIRAS. If peer-to-peer actions occur due to failure of staff to intervene to prevent or stop the act, a neglect report is appropriate. In cases where one individual is clearly the aggressor, it is acceptable to make only one CIRAS entry in the name of the aggressor, listing the name(s) of the victim(s) in the narrative. However, if two or more people become involved in an altercation that meets this definition and the aggressor is identified as multiple individuals, a separate CIRAS report should be completed for each aggressor.  Acts committed against staff should be reported in the "Peer-to-staff" option.

Peer-to-staff: Acts committed by one individual against one or more staff members when there is physical abuse with intent to harm or verbal abuse with intent to intimidate, harass, or humiliate. In cases where one individual is clearly the aggressor, it is acceptable to make only one CIRAS entry in the name of the aggressor, listing the name(s) of the victim(s) in the narrative. However, if two or more people become involved in an altercation that meets this definition and the aggressor is identified as multiple individuals, a separate CIRAS report should be completed for each aggressor.

Unauthorized restraint: Any use of restraint beyond the provisions outlined in Appendix G of each Waiver. Refer to Illinois Mental Health and Developmental Disabilities Code for details. (See 405 ILCS 5/1-125 and 405 ILCS 5/2-108 for details.)

Unknown injury: Any injury of an unknown cause that is not considered possible abuse or neglect and that requires treatment that only a physician, physician's assistant, or nurse practitioner can provide. If the cause of the injury is known, follow instructions in KNOWN INJURY and/or MEDICAL EMERGENCY categories.

Unscheduled hospitalization: Any hospital admission that is not scheduled in advance. Hospitalization admissions that occur as a result of a "Medical emergency" or "911 call" should not be reported in this category but should be reported in the appropriate category.

Enrollment in CIRAS

ISC Agencies

ISC agencies must enroll in CIRAS to be able to report CIRAS incidents, receive critical incident notifications, and review CIRAS reports. The enrollment process consists of completing the documents below. In addition, ISC agencies must select designated agency reporters who must complete the steps shown in section "ISC and Community Provider Agencies (Designated Agency Reporters)" of this manual.

  • Model Business Associate Agreement
  • Data Sharing Agreement Security and Privacy Controls Questionnaire

Model Business Associate Agreement

    • The Model Business Associate Agreement is a standard form required by the DHS General Counsel Division to establish confidentiality standards related to the Health Insurance Portability and Accountability Act (HIPAA). The form will be provided to the ISC agency by the Division of Developmental Disabilities. The ISC agency will need to have the Executive Director or designee sign on the last page under, "Business Associate Representative." The signed form must be returned via email to DDD.
    • CIRAS unit. Upon approval, a copy of the form will be forwarded to the ISC for their records. The agreement is completed biannually and will be kept on file by DDD.
  • Data Sharing Agreement Security And Privacy Controls Questionnaire

DDD will supply a Data Sharing Agreement Security and Privacy Controls Questionnaire to all ISC agencies. ISC agencies will have a unique agreement number included in their enrollment packet. Once completed by the Executive Director, it must be submitted to DDD by email to: DHS.DDD.CIRAS@illinois.gov.
In order to ensure that baseline security and privacy controls are met, each ISC agency will need to complete the Data Sharing Agreement Security and Privacy Controls Questionnaire. The first page includes completion instructions. A Data Sharing Agreement Questionnaire will be sent to each ISC agency for initial enrollment with the individual ISC's designated DSA number included. Upon approval, a copy of the form will be forwarded to the ISC for their records. The agreement is completed annually will be kept on file by DDD. 

ISC and Community Provider Agencies (Designated Agency Reporters)

ISC and community provider agencies must select designated agency reporters who must complete the following steps.

At a minimum, two (2) designated agency reporters must be registered for CIRAS per agency to assure staff are always available for timely reporting of incidents.

Certificate Of Understanding And Acknowledgement For CIRAS

Each ISC and community provider agency is required to have the designated agency reporter(s) complete and sign this form. The copies are maintained at the agency and are part of a security audit trail. The Certificate is available at this link:

Certificate of Understanding and Acknowledgment for the Critical Incident Reporting and Analysis System (pdf)

Community Provider/External User I.D. And System Access Request (IL444-2022)

  1. Initially, users must request an external user I.D. by clicking on the link below. If the CIRAS user has an existing external I.D (that is, an active directory ending in @external.Illinois.gov, also known as DHS I.D.) then proceed to Step 2 below.
    1. Click this site: DoIT Identity Management
    2. Once at the DoIT website, select the option for "Create Illinois.gov Account" and then follow the prompts.
    3. The DoIT website will generate the external user I.D and email it to the work email address. The external user I.D. is the CIRAS username and will be necessary to log into CIRAS.

Note: Passwords established for CIRAS will expire 60 days automatically without user notification. To reset the CIRAS Password, click on the following link, Links to Important CIRAS Resources. Once at the website, click External ID Password Changes. Follow steps appearing on the "External.Gov Email Password Recovery Steps" website.

  1. Next, users must complete the IL444-2022 form after being assigned an external user I.D.
    1. The IL444-2022 is used to provide DHS system access for a variety of functions, including CIRAS. This form is available from the DHS website by clicking on the following link called Community Provider / External User I.D. And System Access Request (pdf). For community provider agencies, the form is also included in the initial enrollment packets.
    2. For examples, see:
      1. IL444-2022 ISC Agency Sample Template (pdf)
      2. IL444-2022 Community Provider Agency Sample Template (pdf)

The following steps should be taken to complete the IL444-2022 for CIRAS access(must have an active directory I.D. prior to completing this form):

Steps to follow:

Action Requested:

Check the box "System Access Only (ID Previously Assigned)"

Community Provider Information:

FEIN No.: indicate agency FEIN No.

Agency Number: Leave blank

Provider Name (Required): Indicate Agency/Provider NameIGA/DSA No. (Required):

  • ISC - Provide the ISC CIRAS designation number provided with initial enrollment packet.
  • Community Provider - indicate * "Impact Terms and Conditions"

Medicaid ID Number: Leave blank


User Information:

Complete information as requested for the designated CIRAS reporter.

The IDHS ID will be the external user I.D. (for example, John.Doe@external.illinois.gov). This will be the email address assigned from the Create Illinois.gov account steps. If the CIRAS reporter has an existing external.illinois.gov email address, input that existing .gov address.


User System Access Requested:

Check the "Other" box and indicate "CIRAS & CMA"

To Be Completed for all Transactions Except "Delete User ID":

User indicates their printed name, sign their name and add date.

Approval Signatures (required):

The agency executive director indicates their printed name, sign their name and add date.

IDHS Program Approving Authority section:

leave blank

Completion

Once completed, forward the form along with form IL444-4144 to : DHS.DDD.CIRAS@illinois.gov

Request for MIS Hardware, Software and Services (IL444-4144)

The IL444-4144 form is used to provide access to the reports, viewed through the InfoView portal, from the Reports tab on the CIRAS site. The IL444-4144 form is available from the DHS website by clicking on the following link called Request for MIS Hardware, Software and Services (pdf). For community provider agencies, the form is also included in the initial enrollment packets.

For examples, see:


The following steps should be taken to complete the IL444-4144 for CIRAS report access (must have an active directory I.D. prior to completing this form):
Steps to follow:

Requestor
  • Indicate name of staff person requesting/reporting in CIRAS.
  • Division: Leave Blank
  • Bureau/Facility: Leave Blank
  • Telephone No: indicate telephone number of requestor
  • Contact: provide information for requestor/reporter name; address;
  • city/zip; phone number.
  • State Fiscal Year (SFY): Indicate current, 2-digit State Fiscal Year. For
  • example, for FY 2021, indicate 21. The 2-digit number
  • changes annually.

Recipient
  • Indicate name of staff person requesting/reporting in CIRAS.
  •  Division: indicate "DDD"
  •  Office: indicate agency/provider name
  •  Bureau/Facility: Leave Blank
  •  Address: indicate address of recipient
  •  City and Zip Code: indicate city and zip code of recipient
  •  Telephone No.: indicate telephone number of recipient
  •  Location Code: Leave Blank
  • Active Directory ID: indicate the requestor/reporter's external.illiois.gov email address here.
  • Remaining Fields - Leave the next four fields blank (that is, User I.D (Novell) through *Required Estimated Total Cost).

ISC

Narrative Description of Request. Indicate the following:

Please register xyz@external.illinois.gov (ISC staff person's external ID information will go here in place of the xyz@external.Illinois.gov) with the roles in TAM/SAM.

  1. DHS_CIRAS_isc
  2. DHS_CIRAS_reporter
  3. DHS_CIRAS_user
  4. DHS.G.CIRAS_ISCProviderExternalReporting

Justification. Indicate the following:

User needs access to report in CIRAS & CMA databases.


Community Provider Agency

Narrative Description of Request. Indicate the following:

Please register xyz@external.illinois.gov (community provider staff person's external ID information will go here in place of the xyz@external.Illinois.gov) with the roles in TAM/SAM.

  1. DHS_CIRAS_reporter
  2. DHS_CIRAS_user
  3. DHS.G.ProviderExternalReporting
  4. DHS_DD_QR_PM_user for CMA

[For completion of new forms due to change in provider FEIN number, add a statement to reflect reason for new form, such as: "Please remove xyz@external.illinois.gov from Provider Name FEIN# ___-___________ due to merge of Provider Name FEIN # ___-___________ with Provider Name FEIN # ___-___________ .

Add xyz@external.illinois.gov to Provider Name FEIN # ___-___________."

Contact DHS.DDD.CIRAS@illinois.gov for questions regarding completion of this form.]

Justification. Indicate the following:

To report in CIRAS & CMA databases.


Division Approval and Page Two
All fields should be left blank.

Completion

Once completed, the form along with form IL444-2022 should be forwarded to: DHS.DDD.CIRAS@illinois.gov.

REPORTING CRITICAL INCIDENTS THROUGH CIRAS

The list of definitions ("Critical Incidents Defined"; refer to beginning of this user manual) and data elements shown below will aid in completing the Incident Report.

[Note: an individual must be registered in the Reporting of Community Services (ROCS) system for the provider agency to enter incidents in CIRAS for the person.]

Critical Incident Tracking Data Elements

All reporters, community providers and ISC agencies will need to gather the following details to complete a CIRAS report.

DATA ITEM DEFINITION/COMMENTS
Participant's Name (3 separate data fields for First, Last, Middle Initial) Enter the name of the individual served under the Medicaid Waiver program.
Participant's Social Security Number Enter the individual's social security number.
Participant's Date of Birth Enter individual's date of birth.
Participant's Gender Enter individual's gender.
Waiver Type Enter adult or children's waiver.
Provider's Name Enter the name of the provider organization reporting the critical incident.
Provider's FEIN Enter reporting organization's FEIN.
Date and Time of Report (2 separate items) Enter date and time incident occurred or when it was discovered.
Name of Reporter Enter the name of the individual making the report on behalf of the provider.
Date of Critical Incident Enter the date the incident occurred or when it was discovered.
Time of Critical Incident Enter the time the incident occurred or when it was discovered.
Type of Critical Incident Enter type of critical incident.
Location of Critical Incident Choose one of the following from the drop-down menu: Residence, Day Program Site, School, Work Location, Community Outing, Family Visit, or Other.
Incident City Select the city where the incident occurred. Note: Attention should be given to providers with locations throughout the state to assure the correct city is selected. Do not include name of neighborhood.
ISC Provider for Individual Enter the ISC providing services for the individual. An automatic email notification will be sent to the selected ISC. Due to a priority response by the ISC for specific incidents, it is imperative to select the assigned ISC. Thus, appropriate actions and timely follow up can be initiated upon receipt of the email notification.
Narrative Description of the Critical Incident

Provide a narrative of the incident including information on what happened, when (date/time) and where the incident occurred, outcome of the incident, and any staff name(s) (and their working title) or other individuals who were involved. Include other applicable dates, where circumstances occurring on those dates had impact on the reported incident.

Assure to include any pertinent information reflecting the current status (ex.: person has been discharged from hospital; missing person has been located).

The narrative should reflect sufficient details to accurately describe the incident.

Action Provide a narrative of the provider's response to the incident. It should reflect sufficient details to accurately describe the response, including date/time of response, staff name(s) (and working titles) of persons responding, action steps taken to immediately address the incident, and the incident status at the time of the report.

Timeframe for Reporting Incidents

Providers must report incidents within two (2) working days of discovering or being informed of the incident. Since the incidents reported through CIRAS do not involve allegations of abuse, neglect, or exploitation, providers are given more time to compile and report information ensuring it is complete and accurate for trend analysis.

Entering Incidents in CIRAS

To enter CIRAS, the user ID will be the entire external user I.D. (for example, John.Doe@external.illinois.gov) that was received when registering for CIRAS through the IL444-2022. The password used to enter CIRAS is the same password established when the external.gov email address was requested. 

Community Providers and ISC agencies (The Reporter) will access CIRAS through a web link:

CIRAS Reporting Database


The Reporter will see the System Login screen:

Login Screen for QA Environment


After entering the User ID and password, the following screen will appear:

CIRAS Main Screen


To report a critical incident

  1. The Reporter will select the "Search" tab located in top left of the page, and the Participant Search screen will appear.
  2. The Reporter will enter the individual's Social Security Number in the "Participant SSN" field and select the Search button.
    1. If an incident has not been reported for the individual, the Participant Search Results screen will appear.
    2. In situations when no results are found, the agency is required to complete a ROCS case entry to register the individual in order to submit a critical incident report.
  3. If an incident has been reported for the individual, the Participant Search Results screen will appear with the following information:
    1. Upon successful entry of the SSN, provider will verify the following:
      • The individual's SSN
      • The Provider Name
      • Participant First Name
      • Participant Middle Name
      • Participant Last Name
      • Gender
      • Date of Birth
    2. After verifying, the provider can
      • Select a case by clicking the SSN
      • The Incident report will open
  4. All text boxes and drop down boxes must be completed on the Incident Report screen. 
    1. The following information are already shown:
      • The Provider's name
      • The Provider's Fein number
      • Who the report was made by
    2. The following drop down boxes that need filled out {Note: Asterisks (*) are required to be filled out}:
      • *First name 
      • Middle Name
      • *Last Name
      • *SSN
      • *Birth Date (mm/dd/yyy):
      • *Gender (M/F):
      • Date of Incident Unknown
      • Date the incident occurred as observed or reliably reported (mm/dd/yyy):
      • Time of Incident Unknown
      • Time of day that the Incident occurred as observed or reliably reported.
  5. The description is a narrative that reflects sufficient details to accurately describe the incident.

  6. The action reflects the provider's immediate response to the incident.
  7. Once the mandatory fields and narrative blocks have been completed, click on the Save button.
  8. The incident will be reported to:
    1. Independent Service Coordination Agency (ISC)
    2. When appropriate, the Division of Developmental Disabilities.

Change in provider FEIN number: Impact on CIRAS Reporting for Individuals and Designated Agency Reporters


Steps to complete:

If the FEIN number for a provider agency is changed (example: due to new acquisition, merger), then the provider must complete the following steps to assure individuals served and designated agency reporters are associated with the appropriate provider agency in the CIRAS system:
  1. Contact DDD staff in the Bureau of Community Reimbursement and Program Support to determine the appropriate documents/forms to submit to the DDD. The Bureau will provide guidance on updating the provider's information in the ROCS system.
  2. Update information of impacted individuals in the ROCS system to reflect the new provider FEIN number.
  3. Complete new forms (IL444-2022 (pdf) and IL444-4144 (pdf)) for the designated agency reporters. For IL444-4144, add an appropriate statement to the "Narrative Description of Request" section of the form to reflect reason for submission of a new form. For information on how to complete these forms, refer to "Enrollment In CIRAS" section of this manual.

 Once completed, both forms should be forwarded to:

 DHS.DDD.CIRAS@illinois.gov

Notifications of CIRAS Incidents

ISC Agencies

Once a provider reports an incident through CIRAS, a report alert is sent to the default email address for each ISC agency.

ISCs may change the preloaded email address or they may also add additional email addresses. Once an ISC agency receives their User ID and password, the email address changes may be made.

ISC Agency Response to Notifications

ISCs will receive notification via email of each incident reported. They will incorporate the report information into their next scheduled monitoring event or sooner. The notifications listed below will be flagged as priority for review within one working day upon receipt of the email and require follow-up action and documentation:
  • Law Enforcement
  • Missing Individual
  • Unscheduled Hospitalization
All CIRAS submissions require a follow-up entry by the ISC within 10 working days of the initial report. This follow-up should be entered in CIRAS for DDD tracking. The Search function in CIRAS is to be used to locate the incident and then enter the follow-up notes. Use of another reporting system does not replace a follow-up entry in CIRAS.
ISCs will follow the Problem and Conflict Resolution Protocol for all critical incidents in order to determine when incidents should be referred to the DDD for action.

DDD Staff Responsibilities for Individual Incident Review

The system will alert Quality Management Staff in the CIRAS unit of all incidents involving:

  • Death (of individual who received services while living in their own or their family's home)
  • Law Enforcement
  • Missing Individual

DDD staff will contact ISCs within one working day following receipt of the e-mail to ensure necessary action is underway and continue to monitor the situation until it is resolved.

The DDD will address all incidents referred to the DDD for action by ISC agencies. If necessary, Bureau of Quality Management (BQM) staff will coordinate with Regions staff to address the incident. Region staff will follow the Problem and Conflict Resolution Protocol and its time frames.

BQM staff will be made aware of all incidents reported regarding participants selected for the annual review sample prior to conducting on-site visits. Staff will review follow-up of the incidents reported involving sample participants. Should any unreported incidents be identified, staff will identify that as a find inclosing and require a plan of correction.

BQM staff in the CIRAS unit will review a random sample of reported incidents selected by the OA's Information Technology section to ensure reports are complete and that appropriate action steps were taken in response to the incident.

REMOVING STAFF/USER NAMES FROM CIRAS

Providers and ISC agencies have a responsibility to ensure access to CIRAS data is maintained in a confidential and protected manner. To remove staff, each agency should ensure HIPAA standards by completing the IL444-4144 (pdf) as indicated below.


The following steps should be taken to complete the IL444-4144 for removal of staff/users from CIRAS:


Steps to follow:

Requestor
  • Indicate name of staff person needing removal from CIRAS database.
  • DDD: Leave Blank
  • Bureau/Facility: Leave Blank
  • Telephone No: Leave Blank
  • Contact: provide information for requestor/reporter name; address;
  • city/zip; phone number.
  • State Fiscal Year (SFY): Indicate current, 2-digit State Fiscal Year. For
  • example, for FY 2021, indicate 21. The 2-digit number
  • changes annually.

Recipient

  • Leave the first eight fields blank (that is, Recipient through Location  Code).
  • Active Directory ID: indicate the requestor/reporter's external.illiois.gov email address here.
  • Remaining Fields - Leave the next four fields blank (that is, User I.D (Novell) through *Required Estimated Total Cost).

Narrative Description of Request. Indicate the following:

  • Please remove the user "Active Directory ID of user" from the AD group  shown in the item list.
  •  Example: "Please remove the user John.Doe@external.illinois.gov from  the AD group shown in the item list."

Justification. Indicate the following:

1) For Providers indicate: "DHS.G.CIRAS_ProviderExternalReporting"

  ISC agencies indicate: "DHS.G.CIRAS_ISCProviderExternalReporting"

 2) "Required for reporting"

 3) Indicate Agency Name, and FEIN number, and

 4) "Employee No longer works here" or "Employee no longer in user role"


DDD Approval and Page Two

All fields should be left blank.

Completion

Once completed, both pages of the form must be emailed to DHS.DDD.CIRAS@illinois.gov.

DATA REPORTS AND ANALYSIS

CIRAS Data Reports for ISC Agencies and Community Providers

Community providers and ISC agencies have the ability to review standardized reports from the CIRAS system. ISC agencies will be able to review reports for all incidents sent to them. Community providers will be able to see only the reports regarding the incidents they have reported.
Reports may be viewed from the Reports tab on the CIRAS site. The reports are viewed through the InfoView portal which requires the external user I.D. to login.
The InfoView Manual is available by clicking on this link InfoView Manual.

Summary Reports and Trend Analysis

Summary reports will be developed for trend analysis as follows:

  • Deaths. This report will be sorted by Service Facilitation agency and will display all data elements, including the narrative detail. BQM and Executive Management staff will review this information on a quarterly basis.
  • Type of Critical Incident. This report will count and display the types of critical incidents in descending order of the most frequently reported types for the previous quarter and fiscal year-to-date.
  • Time of Critical Incident. This report will count and display the number of incidents reported in each hour of the day for the previous quarter and fiscal year-to-date.
  • Date of Critical Incident. This report will count and display the number of incidents reported in each month of the year for the current fiscal year.
  • Location of Critical Incident. This report will count and display the number of incidents reported at each location type for the previous quarter and fiscal year-to-date.
  • Participant's Age. This report will count and display the number of incidents reported by age groupings (e.g., 18 through 21, 22 through 29, 30 through 39, 40 through 49, 50 through 59, 60 through 69, 70 through 74, 75 through 79, 80 through 84, 85 through 89, 90 and above) for the previous quarter and fiscal year-to-date and compare that data to the number of participants by age groupings.
  • Participant's Gender. This report will count and display the number of incidents reported for males vs. females for the previous quarter and fiscal year-to-date and compare that data to the number of male vs. female participants.
  • Number of Critical Incidents by Provider. This report will count and display the number of critical incidents for the previous quarter and fiscal year-to-date for each provider and compare that data to the number of participants at each provider. The report will be sorted in descending order with the providers with the highest incident rate per 100 census listed first.
  • Type of Critical Incident by Provider. This report will count and display the types of critical incidents in descending order of the most frequently reported types for the previous quarter and fiscal year-to-date for each provider.

Review of Trend Reports

Reports will be produced by the system on a quarterly basis. They will be reviewed and discussed with Medicaid Agency staff. Additional reports may be identified and developed as needed.