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Critical Incident Reporting System (CIRS). Linda Metzger Colorado Department of Health Care, Policy & Financing. Any actual or alleged event or situation that creates a significant risk of substantial or serious harm to the health or welfare of a client.

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Critical Incident Reporting System (CIRS)

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critical incident reporting system cirs

Critical Incident Reporting System (CIRS)

Linda Metzger

Colorado Department of Health Care, Policy & Financing

what is a critical incident

Any actual or alleged event or situation that creates a significant risk of substantial or serious harm to the health or welfare of a client.

  • Could have or had a negative impact on the mental and/or physical well being of a client in the short or long term.
What Is a Critical Incident?
applicable waiver programs

Persons with Brain Injury (BI)

  • Persons with Mental Illness (MI)
  • Persons Living with AIDS (PLWA)
  • Elderly, Blind & Disabled (EBD)
  • Persons with Spinal Cord Injury (SCI)
  • Children with Life Limiting Illness (CLLI)
  • Children’s HCBS (CHCBS)
  • Children with Autism (CWA)
Applicable Waiver Programs
why does the state need to track critical incidents

To assure that necessary safeguards have been taken to protect the health and welfare of the individuals receiving 1915c waiver services

  • To identify, address and seek to prevent the occurrence of abuse, neglect and exploitation on a continuous basis
  • To comply with key regulatory requirements from CMS regarding monitoring
  • To insure remediation (follow up) actions are initiated when appropriate
Why does the State need to track Critical Incidents?
critical incidents and the department s quality improvement strategy

Monitoring Critical Incidents is a part of the Department’s Global Quality Improvement Strategy encompassing three functions:

  • Discovery
  • Remediation (Follow-Up)
  • Continuous Improvement
Critical Incidents and the Department’s Quality Improvement Strategy
providers of waiver services

Waiver services are furnished at widely dispersed sites throughout the community

  • Typically include: large and small private-sector provider organizations, assisted living facilities, adult day care facilities, case managers, individual personal assistants and attendants, clinicians, neighbors and other community members who support individuals
Providers of Waiver Services
number of critical incidents reported per month

There was a significant increase in reporting over the past 3 years.

  • 2009 100/month
  • 2010 150/month
  • Jan.-June 2011 200/month
  • July-Dec. 2011 300/month
  • Jan.- July 2012 500/month
Number of Critical Incidents Reported per Month
reporting issues

Some providers are very diligent about reporting critical incidents to SEP/CMAs

  • Some agencies understand the CIR reporting process and expectations well and others do not
  • Some agencies are over-reporting incidents, e.g. reporting unnecessary events
  • Some SEP/CMA regions have a high frequency of critical incidents while others have a low frequency
Reporting Issues

Timely Reporting Requirements

HCBS Waiver Service Provider Case Manager

( within 24 hours or one business day)

Case Manager HCPF (BUS)

( within 24 hours or one business day)

Follow-up and investigation

Case Manager responsibility?

Provider responsibility?

Other entity Responsibility?

provider reporting forms

Provider Services>provider services>forms>Critical Incident reporting systems forms

1.HCBS Provider Critical Incident Information Form

2. Provider Critical Incident Follow-Up Form

Provider Reporting Forms
types of critical incidents to report


  • Suspected Abuse/Neglect/Exploitation
  • Serious Illness
  • Injury to Client
  • Damage to Client’s Property or Theft
  • Medication Management
  • Other High Risk Issues
Types of Critical Incidents to Report

Death Types

  • Ongoing Medical Condition/Illness/Disease
  • New Medical Condition/Illness
  • Unexpected/Unknown Cause
  • Completed Suicide
  • Homicide
  • Accidental Death
  • Other
suspected abuse neglect or exploitation

Abuse includes actions which result in bodily harm, pain or mental distress.

  • Neglect is a failure to provide care and service when a waiver client is unable to care for him or herself.
  • Exploitation is the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a client’s belongings or money without the client’s consent.
Suspected Abuse, Neglect or Exploitation
serious illness medical crisis

Recurring Illness

  • Heart attack (MI)
  • Stroke (CVA)
  • Pneumonia
  • Respiratory failure
  • Seizure
  • Infection (UTI)
  • Dehydration
  • Cancer
  • Diabetic Crisis
  • Mental Illness symptoms
  • Medical crisis
  • Other illness
Serious Illness/Medical Crisis

Cause of Serious Illness

  • New medical condition
  • Existing medical condition
  • Treatment error
  • Medication
  • Poor care
  • Undetermined
  • Other
serious injury


  • Laceration
  • Serious Burn
  • Head Injury
  • Multiple injuries
  • Unknown injury from fall requiring medical attention
  • Unknown injury
  • Other injury
Serious Injury
cause of serious injury


  • Accident
  • Seizure
  • Assault
  • Choking/Aspiration
  • Physical Restraint
  • Undetermined
  • Other
Cause of Serious Injury
damage to client s property theft

Deliberate damage, destruction, theft, misplacement or use of a client’s belongings or money without the client’s consent, including the deliberate diversion of medications

Damage to Client’s Property/Theft
medication management

Problems with medication dosage, scheduling, timing, set-up, compliance, administration or monitoring which can result in documented harm or an adverse effect which necessitates medical care.

  • Event Type
  • Cause for event
  • Administered by
Medication Management
other high risk issues

Serious issues that do not yet rise to the level of a critical incident, but have the potential to do so in the future, including such events such as environmental hazards, suicide threats, self-injurious behaviors, arrest or detention, etc.

  • This type of critical incident always requires


Other High Risk Issues
types of high risk issues

Lost/missing person

  • Loss of Home/Eviction
  • Client fraud
  • Provider fraud
  • Serious criminal offense

(offense by client)

  • Client abuse toward others
  • Unusual aggressive behavior
Types of High Risk Issues
  • Suicide ideation
  • Suicide attempt
  • Substance abuse
  • Media involvement
      • Environmental hazard
      • Restraints used
unnecessary or inappropriate reporting examples

Lifeline Activation not related to a specific incident type

  • Reports about non-HCBS persons
  • Due to weakness in his legs, client fell in the dining room, no ER visit
  • Client said she tripped over her dog and fell again
  • Client complained of having severe neck pain
  • Client was scratched on left forearm by dog paw
Unnecessary or Inappropriate Reporting Examples
recording a critical incident report

When reporting a critical incident, be prepared to provide enough information so the reviewer knows:

  • Who was involved in the incident
  • What were the circumstances of the incident - details
  • Where the incident happened
  • When the incident took place, Date & Time
Recording a Critical Incident Report
mandatory reporting responsibilities

Reporting Critical Incidents in the BUS does not relieve the provider, provider agency or SEP/CMA of other forms of mandated reporting, including reports to law enforcement, Child or Adult Protective Services, or Occurrence Reports to the Colorado Department of Public Health and Environment

Mandatory Reporting Responsibilities
after a critical incident is reported

HCPF Waiver Program Staff will review CIRS reports on daily basis checking for completeness of reports to determine if the report:

  • Provides enough detail to understand the circumstances of the incident
  • Documents the steps taken to respond to incident
  • Identifies how client’s safety has been addressed and the follow-up measures taken and/or planned
  • Documents whether mandatory reporting has occurred
After a Critical Incident is Reported
after a critical incident is reported1

There will be instances when additional follow-up by the SEP/CMA will be required:

  • when reports lack sufficient information for the reviewer to understand the nature of the incident
  • how a client or situation has been stabilized
  • what safety measures have been taken to investigate and remedy the circumstances
After a Critical Incident is Reported
cirs entering a critical incident
CIRS – Entering a Critical Incident

After you verified you have the correct client, click on “Critical Incident Reports”

cirs entering a cir
CIRS – Entering a CIR

You can click on “Add New CIRS” or “Add Critical Incident” to start the entry process

cirs entering the incident info
CIRS – Entering the incident info

Make sure all elements are completed

cirs incident specific descriptors

Definition of what types of events are appropriate for each incident type

CIRS – Incident Specific Descriptors

Complete a thorough description of the incident circumstances

Complete the incident specific descriptors

cirs persons involved

After completing the incident descriptors, click “Persons Involved”

CIRS – Persons Involved

Complete the sections for name, relationship to client, and role

Click “Add” to enter additional persons involved

cir mandatory reports made

After completing Persons Involved, click on Mandatory Reporting Steps

CIR – Mandatory Reports Made

Make sure all sections are complete

Click “Add” to enter additional mandatory reports made

cirs follow up actions

After completing Mandatory Reporting Steps, click on Follow-up Actions Taken

Make sure follow-up actions are complete. This section describes the actions take to remedy the situation and/or secure the client’s health and welfare

CIRS – Follow Up Actions

Click “Add” to enter additional follow up actions

cirs referrals made

After Follow-up Actions, click on Referrals Made

Complete a referral screen for each referral completed in relationship to the incident that occurred. Please be descriptive of actions take and reason for referral

CIRS – Referrals Made
cirs persons notified

After completing Referral Steps, click on Persons Notified

CIRS – Persons Notified

Complete all sections of the person notified

Click “Add” to enter additional persons notified

cirs post report follow up

Select Post Report Follow-up to document additional incident related information

CIRS – Post Report Follow-up

Provide narrative description of additional information

hcbs provider reports to sep cma

The Department does not require any specific method of communication between HCBS Provider Agencies and SEP/CMAs

  • A form entitled “PROVIDER CRITICAL INCIDENT REPORTING FORM” has been provided as a means of capturing the detail necessary for reporting incidents; but, it is not a required by the Department.
HCBS Provider Reports to SEP/CMA