New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 308 - MANAGED CARE PROGRAM
Part 21 - QUALITY MANAGEMENT
Section 8.308.21.13 - INCIDENT MANAGEMENT
Universal Citation: 8 NM Admin Code 8.308.21.13
Current through Register Vol. 35, No. 18, September 24, 2024
Critical incident reporting and management is considered part of ongoing quality management. Critical incident reporting and analysis of critical incident data helps to identify causes of adverse events in critical care and areas of focus for implementation of preventative strategies.
A. MCO incident management principles: The implementation of incident management practices and effective incident reporting processes as described in the medicaid managed care services agreement or the managed care policy manual are based on the following MAD MCO principles:
(1) a member is expected to
receive home and community based services free of abuse, neglect, and
exploitation;
(2) training
addresses the response to and the report of to include the documentation of a
critical incident;
(3) a member,
his or her authorized representative will receive information on his or her MCO
incident reporting process; and
(4)
good faith incident reporting of or the allegation of abuse, neglect or
exploitation is free from any form of retaliation.
B. Reportable incidents:
(1) The MCO shall ensure that any person
having reasonable cause to believe an incapacitated adult member is being
abused, neglected, or exploited must immediately report that
information.
(2) The MCO shall
develop and provide training covering the MCO's procedures for reporting a
critical incident to all subcontracted individual providers, provider agencies,
and its members who are receiving self-directed services, to include his or her
employees.
(3) The MCO shall comply
with all statewide reporting requirements for any incident involving a member
receiving a MAD covered home and community based service.
(4) A community agency providing home and
community based services is required to report critical incident involving a
MCO member, including:
(a) the abuse of him or
her;
(b) the neglect of him or
her;
(c) the exploitation of him or
her;
(d) any incident involving his
or her utilization of emergency services;
(e) the hospitalization of him or
her;
(f) his or her involvement
with law enforcement;
(g) his or
her exposure to or the potential of exposure to environmental hazards that
compromise his or her health and safety; and
(h) the death of the member.
(5) The MCO shall provide,
coordinate, or both, intervention and shall follow up upon the receipt of an
incident report that demonstrates the health and safety of its member is in
jeopardy.
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