Timeframe to Report Incidents to the ISDH

State and federal regulations require health care facilities to report certain “incidents” to the Indiana State Department of Health (“ISDH”). Both the ISDH and the Centers for Medicare & Medicaid Services (“CMS”) have expectations of the timing in which a facility must report an incident. The current expectations and rules for both the ISDH and CMS are below; please note, however, that the standards may change once CMS issues the long-awaited memorandum concerning reporting allegations of abuse and neglect. Furthermore, it is likely that the ISDH will alter its guidance to align with CMS once the memo is issued.

According to the ISDH Division of Long Term Care, current CMS regulation concerning incident reporting takes precedent over that of the ISDH policy, and any facility must ensure that incidents are reported to the Administrator and ISDH immediately. The federal regulation, 42 C.F.R. §483.13(c)(2), states the following concerning timeliness of reporting incidents:

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). 
     
The ISDH Division of Long Term Care has indicated that CMS interprets the regulation so that the term “immediately” applies both to reporting to the Administrator and reporting to “other officials in accordance with State law through established procedures.” Id. Furthermore, CMS has maintained that “immediately” means “as soon as possible, but ought not exceed 24 hours after discovery of the incident.”

Guidance from the ISDH Reportable Incidents Policy, accessible in the Members Only section of the IHCA website, is the main source of confusion on whether the Indiana standard for reporting is immediately or within 24 hours. The first sentence of the Indiana guidance states, “Facilities are required by law to report unusual occurrences within 24 hours of occurrence to the Long Term Care Division.” Through discussions with the ISDH Division of Long Term Care, this sentence is not accurate and needs to be revised. However, the language in the Reportable Incidents Policy will not likely change until CMS issues the memo regarding F 223.

CMS surveyors are beginning to cite facilities for alleged failures to report incidents immediately through look-behind surveys. Because of the increased CMS oversight, the ISDH may be changing its approach and begin to more aggressively cite facilities for not reporting incidents immediately. An example of a citation concerning incident reporting in which a facility was cited for failing to report immediately is also available in the Members Only section. Please note that the facility in this example reported 24 hours after the incident occurred, and referenced the ISDH guidance on the 24 hour reporting requirement.  This incident should have been reported sooner.

Below are best practices and key points regarding the current legislation and requirements to comply with ISDH and CMS guidelines for incident reporting.

• “Immediately” does not mean a 24 hour grace period exists to report an incident.
• “Immediately” means as soon as possible once the resident is safe and protected.
    o An example of the immediacy required: If an allegation of abuse has been made and the resident is bleeding, stop the bleeding and then immediately notify the ISDH. You do not stop the bleeding, suspend the employee(s), take witness statements, draw conclusions, and then finally notify the ISDH.
• Use best judgment and report as soon as possible when dealing with “degrees” of incidents, including the time of day in which incidents take place. A common concern is immediate reporting in the middle of the night when the alleged incident is not especially grave or injurious (for example: a bruise of unknown origin discovered at 2a.m.). Immediate in this circumstance may not require an ISDH report by 2:30 a.m.. However, if an allegation of an employee hitting a resident is made at 2 a.m., a report to the ISDH as soon as possible once the resident is safe and protected (which may also require the removal and suspension of the employee) is required. A reasonable time to do this may be an hour, or perhaps a bit more.
• Educate facility staff. The 24 hour window that most believe exists before an incident report must be submitted does not likely exist at all.

If you have questions or would like more information about this, contact Zach Cattell at (317) 616-9001.