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Completing an incident report in Neo

September 05, 2024

Georgana Prudhomme, _LCSW

Why Do We Report and Track Critical Incidents & Sentinel Events

KBH is licensed by DHHS, Office of Behavioral Health, and the Office of Child & Family Services and accredited by CARF which requires KBH to report incidents that fall into the categories of a Level I or Level II incident for adults which we will review in upcoming slides. OCFS has different reporting processes.

In tracking Critical Incidents and Sentinel Events, the KBH Quality team is able to create reports to assist with identifying any trends or concerned areas of services.

As mandated reporters, KBH staff are required to report alleged abuse: physical/sexual, emotional abuse to CPS and financial exploitation of a client. This includes:

What are Sentinel Events & Critical Incidents

•    KBH is accredited by CARF and as one component of our accreditation is KBH tracks and follows Sentinel Events.

•    Sentinel event is defined by CARF as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Death occurring from natural causes are not reported to CARF by the Quality Team.

•    The Office of Behavioral Health (OBH) defines a critical incident as a serious event that creates significant risk of harm to clients, jeopardizes public safety or program integrity, and includes errors or undesirable events.

•    For OBH, ALL client deaths must be reported including medical or death due to natural causes.

The NEO Critical Incident Report is used for tracking and reporting purposes and not intended to replace real-time notifications that may be required in a critical situation.

•      The NEO report is to be completed as soon as possible. Reporting incidents to your Supervisor, Administrator, Clinical Director, or Human Resources, for staff and/or client-related injuries is required as well.

•      If you are unsure if an incident requires reporting in NEO, you may consult with any of the above-named persons.

•      You may also contact the Clinical client-related Training & Quality Manager for clarification of an incident via email at gprudhomme@kbhmaine.org or via telephone at (207)616-8632

KBH Reporting Timelines to Office of Behavioral Health OBH for Level I incidents

Level 1 Incidents for OBH:

Reported within 4 hours from when KBH staff learn about the event:

• Suicide

• Homicide

• Other Death – may be unknown at the time of the report.

• Clinical or Medication error resulting in emergency medical care for the client

• Lost, missing client or client that left the facility AMA in a residential/CSU placement which would rise to the level of Silver Alert and/or under the guardianship, in the Care and Custody of the Commissioner, and/or in violation to conditions of release/court order

• Alleged abuse: physical/sexual, emotional abuse, neglect and financial exploitation of client by a staff.

• Alleged Serious Crime (e.g., arson, assault, hostage) by client with extreme risk of harm to client, staff, or public

• Other serious events (fire, flood, motor vehicle accident in company vehicle with clients, or client’s vehicle, that requires medical attention for staff and/or client(s).

• Natural Disaster, building becomes uninhabitable, incidents that require client evacuation from the building

• Medical Outbreak- is a new category. This relates to a medical outbreak that may close a program or office – or, if the majority of staff are out due to a medical outbreak in the same program and area.

What to do when you learn about a Client Death?

•     Please send an email to deceasedclient@kbhmaine.org noting the client ID number, initials, and if known, state how you were notified of the death and cause if known.

•     This includes front desk staff as well as staff with direct service for the client.

•     All deaths, either medical or undetermined, are reported to the appropriate DHHS department, such as OBH or OCFS.

•     Complete a NEO CIR as soon as possible as a death needs to be reported within 4 hours of KBH learning about the death to OBH.

•     Please provide as much detail as known in the NEO CIR.

•     The Clinical Training and Quality Manager will complete the reporting process.

•     When a NEO CIR is entered, the Clinical Director, Clinical Training & Quality Manager & the Clinical Quality & Training Coordinator receive a NEO alert.

Level II Incidents

Reported within 24 hours from when KBH staff learn about the incident:

•    Alleged Physical/Sexual, emotional abuse, and financial exploitation of client by someone other than a provider staff

•    Suicide attempt that requires medical intervention

•    Self-harm that requires medical attention

•    Lost or missing client or client left the facility AMA in facility )PNMI residential/CSU Placement client (for more than 24 hours)

•    Medication/Drug Diversion

•    Wellness Check

•    Major Physical Plant Disaster

•    Duty to Warn - at this time use the Other Serious Event Check Box as the form will be updated to include the title in the near future.

•    Neglect – is a pattern of conduct, engaged in without the patient’s informed consent, resulting in deprivation of food, water, medication, medical services, shelter, cooling heating, or other services necessary to maintain minimum physical or, mental health.

•    Examples:  Malnutrition, Dehydration, Pressure sores, Unsafe or Unsanitary living conditions, Untreated medical problems or refusal of medical care, shelter, cooling or heating or other services to maintain minimum physical or mental health.

Children’s Critical Incidents

•      If a report is made to Child Protective Services, we do not need to complete a NEO CIR form.

•      Generally speaking Clinical Quality reports a child’s death, serious suicide attempt, or dangerous situation using the EIS system.

•      If a client injury or other situation arises, if the incident occurred outside of KBH service delivery at the time of the incident, we do not need to report these situations to OCFS. For example, if a client runs away and steals a car, it is not reportable to OCFS unless a KBH staff person was present providing services at the time of the incident.

How To Complete an Incident Report in Neo

•      Please complete the form as soon as possible.

•      In the event of an injury or EMS involvement, please report after everyone is safe.

•      Please share this information with your staff in order to assist them in knowing what and how to report an Incident in NEO.

•      After this presentation, if you would like training for your staff at a team meeting, this can be arranged.

Search Incident Reports Screen:

Click on the Add button which will open the Incident Report window.

After selecting the type of event, note the date of the incident and not the date you are entering the incident. If you know the time of the incident enter it in the box shown below. Otherwise, click the Unknown button. Note the Incidents are now listed in alphabetical order.

If you are a staff person, and are unsure which category to select, use the Incident Types Descriptions tab by clicking directly on the tab. This will bring up the Incident Type and Description text box to assist in determining what category to select. If you are still unsure which category to select, enter a category and the Clinical Quality team will make any needed corrections to the category selected. 

The following are definitions provided in the Incident Type Description. Please note Medical has changed to Medical Event Emergent and Non-Emergent. 

Please note Neglect is a separate Category; Psychiatric Event also has Emergent and Non-Emergent; and Self-Harm has been changed to include “requires medical attention.”

Please note that Sexual stand-alone Assault is a separate stand-alone category. Wellness Check is a new additional category.

Add the Client ID & the Information will Auto Fill. Enter the Provider in the box designated below. If the incident involves additional staff use the Add New Provider box marked below.

When you select a provider if the box did not pre-populate, you will select a provider or enter the provider type; agency, even if KBH; Clinician/Staff; Program and Save. If you have notified other staff please click the box for Informed.

Summary Section

 •      In this section you will enter what occurred. Please add enough information in the Summary textbox to make it clear as to what occurred, who was involved, and any other relevant information, in order to assist the Clinical Training & Quality Manager or Administrators, in reporting the incident. Providing clarity here is important in capturing a picture or understanding of what the incident involved when we report the incident.

•       For example, the Client’s sister called Jane at the Med Clinic to report the client passed away last night.

•      If this is a staff incident, state what occurred.(Please note all staff injuries are handled by Human Resources)

•      For example, Jane Doe twisted her ankle coming down the stairs, missing the last step, and is limping with a swollen ankle.

 Outcomes Text Box

 •   In the Outcomes text box please document what you know happened after the incident Summary has been completed, if known.

•   In an incident Summary section, an example may be: a client reports he took 50 Tylenol in a suicide attempt and then told his partner.

•   The Outcome may be that his partner called 911; EMS arrived; and took him to the MGMC ER for treatment. His partner met him in the ER and stayed until he was admitted to the unit.

•   In the staff injury, you may document if the person left for medical care; or consulted with HR; and if it was recommended the staff person go to Employee Health. No details about the injury are documented here.

The Admin Response Text Box

 •      The Admin Response text field should be left blank by the staff person entering the incident report.

•      The Clinical Quality &Training Manager, Supervisor, Director, or Administrator can use this field to note any actions taken, if necessary.

•      In this text field the Clinical Training & Quality Manager documents actions taken re: reporting the incident to OBH or the Office of Child and Family Services(OCFS).

•      Once the Incident is submitted you will no longer be able to see the incident.

Submitting the Form

•     Once you have entered the Client ID; client’s providers; documented what occurred in the Summary; and, if you have information to document re: outcomes; next, you will select your supervisor in the drop-down menu and Send the form. Then you select your supervisor and click Submit.

•     Clinical Quality receives a notification when an incident is submitted. The incident is reviewed and actions taken appropriate for the information presented. The Incident will be sent to the supervisor or Administrator, who will submit the form after reviewing the case.

That is how you successfully submit a NEO Critical Incident Form.

•      Questions – If you have any questions re: using this form, please speak with your Supervisor, Director, or Administrator.

•      For backup, you may contact Georgana Prudhomme, LCSW, at gprudhomme@kbhmaine.org

•      When Georgana is out of the office, Jody Bucknam is the backup contact at jbucknam@kbhmaine.org