Purpose and Scope

The aim of this policy is to safeguard the wellbeing of Carinya Society’s participants and residents*.

(*referred to as “clients” in this document)

The application of this policy applies to all staff and volunteers of Carinya Society.

Policy

Carinya Society is committed to minimising the potential risk of harm to people through analyzing, managing, reporting and the ongoing monitoring of incidents.

Incidents involving provision of services under the Disability Act 2006

For services provided under the Disability Act, where an incident involves:

• a state-funded client
• clients who have yet to transition to the NDIS or
• clients receiving in-kind services

Incidents should be reported to the DHHS using the relevant incident reporting mechanism.

Where an incident also involves worker misconduct, providers must notify the DWES Unit if any of the four DWES notification criteria are met.

See also the Disability Worker Exclusion Scheme Instruction.

Incidents involving NDIS participants

Where an incident involves an NDIS participant, registered NDIS providers must comply with the incident management reporting requirements of the NDIS Quality and Safeguards Commission as outlined in the National Disability Insurance Scheme (Practice Standards – Incident Management and Reportable Incidents) Rules 2018 and guidance materials. Reportable incidents include worker misconduct. See also Reportable Incidents in Victoria from 1 July 2019 – Factsheet for service providers – June 2019

 Incident reporting supports the provision of high quality services to clients through the full and accurate reporting of adverse events and subsequent analysis/investigation, to enable the development of actions and strategies to prevent reoccurrence.

Carinya Society acknowledges that effective management and review of incidents both minimizes risk and improves quality of service provision.

It is the responsibility of Carinya Society to:

• Collect the required information regarding incidents;
• Complete relevant reporting requirements to the relevant regulatory authority, including confirming categorisation and classification of incidents (where relevant);
• Identify trends;
• Document actions undertaken, and actions planned, in response to the client incident and record on the client file;
• Maintain a client incident register that captures the minimum required information for reporting;
• Respond to follow-up requests from the relevant regulatory authority as appropriate.

Procedure

Incidents involving provision of services under the Disability Act 2006 The DHHS Client Incident Management Guide, which outlines the use of the Client Incident Management System (CIMS), is to be used for all Major Impact and Non-Major Impact incidents. Staff are to utilise the CIMS to draft and submit incident reports. Relevant information is also recorded on Carelink and the Incident Register.

What is a client Incident?

An event or circumstance that occurred during service delivery, which resulted in harm or has the potential to harm a client.

This includes both major impact incidents and non-major impact incidents. It also includes data breaches which are also required to be reported to the Office of the Australian Information Commissioner. The notification to the Commissioner should be made through the Notifiable Data Breach form.

(Note that this excludes incidents that affect staff or members of the public that do not have an impact on a client. Refer to Staff Incident / Injury Reporting procedure (OHS) and Incident Investigation Procedure (OHS) for the management and reporting of these incidents).

Responding to an Accident

In the event of an incident that causes harm to a client staff should provide:

Immediate response

This involves ensuring the immediate safety, health and wellbeing of the client and other involved parties, obtaining medical attention, notifying Victoria Police and other emergency services as appropriate, notifying relatives, carers, friends or advocates as appropriate, preserving evidence, accessing specialist victim and support services as required and contacting the nominated key support person. It also means taking any remedial action necessary to re-establish a safe environment.

Carinya Management will ensure that when allegations involving staff from another service provider are reported to them, this information will be passed on to the other service provider as soon as practicable to ensure the safety of clients and staff. Carinya Management will ascertain and make initial contact with the relevant senior management representative of the service provider as soon as possible and then forward a pdf’ed, de-identified copy of the Carinya Incident report when completed. Carinya will seek to ensure a collaborative and open information sharing and corrective action approach, as appropriate, to enable a timely and effective resolution of the incident within the bounds of confidentiality and privacy legislative and regulatory requirements.

Ongoing support

These responses involve supporting the client’s wellbeing by ensuring a safe and secure environment, whilst also providing and managing any rehabilitation, counselling or other support they may need in the future in response to the incident.

Chapter 2 of the DHHS Client Incident Management Guide outlines specific responses to some situations including reporting alleged criminal acts and maintaining evidence, fulfilling agency obligations under the reportable conduct scheme and reporting deaths to the Coroner.

Staff should be conscious of these requirements and seek advice from the CEO, Client Services

Manager or delegated authority about how to proceed in these situations.

TYPES OF INCIDENTS

There are 2 categories of reportable incidents:

MAJOR IMPACT

Major Impact incidents are the most serious incidents that can occur at our service and must be reported within 24hrs.

WHAT IS A MAJOR IMPACT INCIDENT?

• The unanticipated death of a client.
  Severe physical, emotional or psychological injury or suffering which is likely to cause ongoing trauma.
• A pattern of incidents related to one client which, when taken together, meet the level of harm of a client defined above. This may be the case even if each individual incident is assessed as a non-major impact incident.
• In addition, certain incidents listed in Appendix A: Definitions of incident types are always required to be reported as major impact incidents – for example, allegations of physical or sexual abuse.

Appendix A of the DHHS Client Incident Management Guide provides further clarification for this incident type and should be referred to.

REPORTING MAJOR IMPACT INCIDENTS

1. The employee present will call the Client Services Manager who will also assist the employee to complete the incident report on Carelink +.
2. The CEO or delegated authority will then approve the client incident report and submit it through CIMS to DHHS as well as inform the Board Governance & Risk Committee Directors within 24hrs. (The Board Governance & Risk Committee will determine whether the members of the full Board require notification and will act accordingly). The CEO is responsible for ensuring the Board Governance & Risk Committee is kept up to date on the management / closure of Major Impact incidents.
3. The incident report is saved in the client’s electronic file.
4. The CEO, Client Services Manager or delegated authority should notify their DHHS Local Engagement Officer (LEO) and inform them of the reporting of a Major Impact incident immediately following the lodgment of the report.
5. The Divisional Office may contact Carinya Society to follow up on the incident and ensure further investigations or reviews are taking place as per the DHHS Client Incident Management Guide.
6. An Incident Report may include personal information from a third party, that is, someone who is not a client or employee but perhaps witnessed or was involved in an incident. Where this occurs, the Privacy Policy in relation to collecting information from third parties will apply.

NON-MAJOR IMPACT

Non-Major Impact incidents involve events where the impact of the harm is determined to be less than a Major Impact. These reports will be captured on the client incident register of CIMS and will be submitted as a batch on a monthly basis.

WHAT IS A NON-MAJOR IMPACT INCIDENT?

• Incidents that cause physical, emotional or psychological injury or suffering, without resulting in major impact as defined above.
• Impacts to the client which do not require significant changes to care requirements, other than short-term interventions. For example, first aid, observation, talking interventions or short-term medical treatment.
• Incidents that involve a client but result in minimal harm.
• Incidents that do not otherwise meet the criteria for ‘major impact’ above.

Appendix A of the DHHS Client Incident Management Guide provides further clarification for this incident type and should be referred to.

REPORTING NON-MAJOR IMPACT INCIDENTS

1. The employee will raise the incident on Carelink + (An automated alert will be sent to the Client Service Manager).
2. The incident report will be reviewed by the Client Services Manager or delegated authority within 2 working days and will be logged in the client incident register of CIMS within 5 days of Carinya Society becoming aware of the client incident;
3. The incident report is also saved to the client’s electronic file;
4. The CEO, Client Services Manager or delegated authority will review all Non-Major impact incidents for the month and submit them through CIMS for review by the divisional office in aggregate, by the 5th day of each month.
5. The Divisional Office may contact Carinya Society to follow up on the incident and ensure further investigations or reviews are taking place as per the DHHS Client Incident Management Guide.

INVESTIGATING ALLEGATIONS OF ABUSE, POOR QUALITY OF CARE OR UNEXPLAINED INJURIES

Investigations are required to be carried out for all major impact incidents that involve:

• Abuse of a client by a staff member or another client. Abuse is defined as including physical, sexual, financial and emotional/psychological abuse as defined in Appendix A of the DHHS Client Incident Management Guide.
• Poor quality of care; and
• Unexplained injury

To determine if an allegation made in an incident report is correct based on the civil standard of proof (the balance of probabilities).

An investigation will involve collecting information to ascertain facts which may inform any subsequent criminal, civil, disciplinary or administrative sanctions.

If a criminal act is alleged Carinya Society must notify Victoria Police and seek guidance regarding whether they would like Carinya Society to place their investigation on hold pending the outcome of the investigations. Carinya Society should not question the alleged perpetrator of an alleged criminal act without the approval of Victoria Police.

UNDERTAKING INVESTIGATIONS

The investigation process is defined in the DHHS Client Incident Management Guide and illustrated below: (REFER TO CARINYA SOCIETY INCIDENT INVESTIGATION PROCEDURE FOR DETAIL)

1. The staff member assigned to complete the investigation should complete it using the form CIMS Investigation Plan located on the CIMS website. The investigation report must be completed and finalised within 28 working days of receiving confirmation from the Divisional Office of DHHS regarding the appropriate investigative action.
2. The investigation must comply with the minimum standards set out in the Client Incident
   Management Guide including:

1. Each investigation should have an overall planning process and written plan
2. The investigation should adopt a client centred and rights based approach
3. The investigation should abide by the standard’s principles of good investigations including procedural fairness, confidentiality & privacy, use of appropriate interview techniques; and
4. The finalisation of the investigation with a report that clearly sets out the findings and the foundations for them.

3. Once complete the investigation manager should prepare a response plan. These responses will be logged on the CIMS and will require confirmation once completed;
4. Carinya Society may choose to review the incident that was investigated after the investigation is complete.
5. A person may request a review of the decision to substantiate a finding of the investigation within 14 working days of parties being notified of the outcome of the investigation.
6. Carinya Society will appoint a lead decision reviewer who will undertake the review in accordance with the Client Incident Management Guide.
7. Once the case review has been finalised the CEO or delegated authority signs off on the case review and it is saved to the client file. The Divisional Office of DHHS may request a copy of the review.
8. Determined actions must be logged against the incident in CIMS and the findings must be communicated to interested parties.
9. An Root Cause Analysis (RCA) review must be logged with the Divisional Office of DHHS within 60 working days of receiving confirmation of the review action. Carinya Society must maintain a copy of all reports, risk reduction action plans and outcomes achieved.

DATA ANALYSIS

Incident data analysis includes the monitoring, interrogating and acting on trends identified through the analysis of incident information. The purpose of analysing incident data is to learn from patterns of client incidents in order to safeguard the safety and wellbeing of individual clients, as well as improve the quality of services and the service system.

The CIMS IT is designed to assist service providers such as Carinya Society analyse incident data to learn patterns of incidents and to safeguard the wellbeing of clients. It assists Carinya Society to do this by:

• Understanding what is happening in relation to incidents (that is, with trends in the volume and type of client incidents, key risk areas)
• Understanding why this is happening (that is, what is driving these events – why are certain types of incidents / services / clients / locations seeing increases / decreases in incidents?)
• Informing what Carinya Society can do to produce better outcomes for client safety and wellbeing.

REVIEWING INCIDENTS

An incident review is an analysis of an incident to identify what happened, determine whether an incident was managed appropriately, and to identify the causes of the incident and subsequent learnings to apply to reduce the risk of future harm.

There are two types of incident review that are required:

Case review – a review led by the service provider following a client incident to identify what happened and any process and system issues. This is a less structured and resource-intensive review than a root cause analysis review.

Root cause analysis (RCA) review – a structured review process for identifying the basic or causal factor(s) that underlie an incident, in order to facilitate learning from that incident. It requires trained staff and appropriate resourcing and time, and therefore is only required in certain defined cases.

NB: Every Major Impact Incident requires a review.

UNDERTAKING REVIEWS

The review process is defined in the DHHS Client Incident Management Guide and illustrated below: (REFER TO CARINYA SOCIETY INCIDENT INVESTIGATION PROCEDURE FOR DETAIL)

• A senior manager will review the incident to determine if service systems or processes were a significant causal factor;
• The senior manager will determine in writing if it is recommended if the review will be an RCA or Case Review. The senior manager will utilise the templates for RCA’s and case reviews located at www://providers.dhhs.vic.gov.au/cims
• A case review should be initiated within 72 hours after receiving confirmation of appropriate review action from the divisional office. The review must be completed within 21 working days. The minimum requirements of a case review are set out in the Client Management Guide.
• An RCA review must be completed within 60 working days of receiving notification from the Divisional office that it will be required. An RCA review is a structured process and should be carried out in accordance with the Client Incident Management Guide.

Incidents involving NDIS participants

PURPOSE

This NDIS Incident management procedure is in place to comply with the requirements under the National Disability Insurance Scheme (Incident Management and Reportable Incidents) Rules 2018 in a relevant and proportionate manner based on the scope and complexity of support we deliver and the size and scale of our organisation. Any changes in our provisions of support or the size and scale of our organisation will be reflected in our Incident Management and Reporting policy and procedure  

DEFINITION

Incident:

An incident is defined as an act, omission, event or circumstance. It may mean any of the following:

• Acts, omissions, events or circumstances that occur in connection with providing NDIS supports or services to a person with disability and have, or could have, caused harm to the person with disability
• Acts by a person with disability that occur in connection with providing NDIS supports or services to the person with disability and which have caused serious harm, or a risk of serious harm, to another person
• Reportable incidents that have or are alleged to have occurred in connection with providing NDIS supports or services to a person with disability.

Reportable incidents:

are serious incidents or alleged incidents that result in harm to an NDIS participant and occur in connection with NDIS supports and services. Specific types of reportable incidents include:

• The death of a person with a disability.
• Serious injury of a person with a disability.
• Abuse or neglect of a person with a disability.
• Unlawful sexual or physical contact with, or assault of, a person with disability (excluding, in the case of unlawful physical assault, contact with, and impact on, the person that is negligible).
• Sexual misconduct committed against, or in the presence of, a person with disability, including grooming of the person for sexual activity.
• The use of a restrictive practice in relation to a person with disability, other than where the use is in accordance with an authorisation (however described) of a State or Territory in relation to the person or a behaviour support plan of the person.

RESPONSIBILITIES

Clients and their support team

Should alert staff and / or management of an incident as soon as possible following the incident.

Where possible will contribute to the completion of the incident report form.

Will be supported to engage with the NDIS Commission or any other regulatory or (police) body where necessary.

Will be supported to engage and alternative provider if requested.

(Note: The subject of the allegation for these incidents may be anyone, including a worker, or a member of the general public, as long as the incident occurred in connection with the provision of NDIS supports and services to the impacted person with disability).

Staff

Are responsible for implementing this policy/procedure when necessary
Will receive relevant training
Will alert management of any and all incidents that are brought to their attention or are identified or observed by them
Will support our clients to report an incident when necessary
Will be responsible for implementing any changes to prevent incident

MANAGEMENT RESPONSIBILITIES

Will ensure that all obligations are met regarding reportable incidents
Will track all reportable and non- reportable incident investigations through to resolution
Will design and implement changes to the business to ensure that incidents are prevented from recurring to the best of their ability
Will document all incidents and the implemented modifications to business practice.
Will ensure incidents are captured on the incident register.

PROCEDURE

• The health and well- being of all persons involved in the incident will be assessed immediately.
• Appropriate emergency aid will be applied including calling emergency services if necessary.
• Once the situation is stable, an incident report form would be completed within no later that 24 hours of the incident or the notification of the incident.
• Management will be alerted immediately.
• In the case of a Reportable Incident, the Client Services Manager or CEO would contact the NDIS Commission within 24 hours.
• Relevant documentation will be submitted to the NDIS Commission in accordance with time frames (5 days) and in keeping with Privacy legislation.
• Support and assistance will be provided to the impacted person of an incident (including information about access to advocates and supports), to ensure their health, safety, and wellbeing.
• The impacted person will be asked to provide feedback and input into assessments, investigations and any corrective actions proposed or taken (where appropriate).
• Support will be provided to the client to engage with the NDIS Commission when appropriate.
• All possible cooperation will be provided to the NDIS Commission and any other investigating body.
• Any relevant prevention strategies will be implemented immediately.
• An internal investigation of the incident will be completed.
• Any and all cooperation with the NDIS Commission and any other bodies will be provided.
• Supports to the client may be ongoing throughout the resolution process.
• Support to engage an alternative provider will be given if requested by the client
• A review of the process will take place following resolution.

INVESTIGATIONS

Refer: Incident Management Systems Detailed Guidance for Registered NDIS Providers June 2019

REFERENCES / NOTES

• As of 15th January 2018 Quality of Support Reviews are superseded by the CIMS.
• National Disability Insurance Scheme Act 2013 (Commonwealth)
• National Disability Insurance Scheme (Incident Management and Reportable Incidents) Rules 2018
• National Disability Insurance Scheme (Practice Standards-Worker Screening) Rules 2018.

Related documents:

Carelink+ – How to enter a client Incident
DHHS Client Incident Management Guide and Appendices CARINYA SOCIETY INCIDENT INVESTIGATION PROCEDURE

Responsibility

Implementation:          Management Team
Review:                       Quality Advisor
Approval:                    CEO