NOTIFYING CARELON OF REPORTABLE EVENTS
Reportable events (formerly called Critical Incidents) are incidents or outcomes involving in-network providers and/or HealthChoices members seeking or receiving services under Carelon administered plans that may require further analysis. They also include events that occur during a patient’s transition to home or an alternative level of care. Tracking of reportable events is a contractual requirement for Carelon with the Counties, DHS, and our providers, so it is important to report an occurrence promptly.
Notification to Carelon that a reportable event has taken place must be documented on a Carelon Reportable Event Form and sent to the Quality Management Department via email to Criticalincident@carelon.com or by facsimile to 855-287-8491 as soon as reasonably possible, but ideally within one business day of the date you became aware of the event. Written supplemental notes or a copy of clinical records may be requested.
Reportable Events include but are not limited to the following events occurring within any treatment setting:
|Serious Reportable Events (SREs)
|Trending Events (TEs)
|Attempted suicide while inpatient (or at any provider site) or if needed emergent care and last discharge was within 7 days
|Attempted suicide at any other level of care than inpatient with no apparent provider culpability
|Completed homicide while in any level of treatment
|Attempted homicide in any level of care with no apparent provider culpability
|Death by suicide at any level of care, death by any cause while inpatient for psychiatric /substance use treatment, or death by an unknown cause while in any other level of care
Death of any consumer while at a provider site (regardless of whether or not the consumer is a Carelon member)
|Death by any cause while in any other level of care
|Allegations of sexual or physical abuse/neglect/exploitation by a provider or non-consensual sex between consumers while at a provider site or where services are rendered
Rape, abuse, or assault by staff that is considered founded (witnessed by staff or other consumers, involving an admission by the perpetrator, involving clinical evidence, etc.) regardless of whether a Carelon member was involved or present
|Allegations of sexual or physical abuse/ neglect/exploitation by non-provider (occurring at a provider site or within the member’s home) and consensual sex between consumers at a provider site or where services are rendered
|Assaults while in a facility that require serious medical treatment (urgent/emergent care, such as Emergency Department or Urgent Care visit)
|Assaults while in a facility that require minor or no medical treatment (such as first aid, assessment/monitoring by on-site medical staff)
|Absent without leave from residential provider for longer than two (2) hours and at risk to self or others
|Absent without leave from a residential provider for longer than two (2) hours with no apparent serious risk and did not return with any contraband, illicit substances, etc. This does not include adults leaving voluntary residential treatment if they have been assessed to not be at risk to self or others.
|Undesirable events inconsistent with routine patient care of a serious nature (adverse medical complications, inebriation, etc.)
|Undesirable events inconsistent with routine patient care of a moderate nature
|Breach of Confidentiality
|Parents or guardian taking child AMA from any inpatient setting with child at risk due to AMA (kidnapping, etc.) or adult leaving treatment voluntarily while at serious risk for incarceration or hospitalization (such as demonstrating suicidal ideation or unstable mental or physical health status)
|Serious accidental injuries either in a facility or a provider site (wherever services are rendered) requiring urgent/emergent life-saving care or skilled nursing (such as Emergency Department or Urgent Care visit)
|Non-serious accidental injuries either in a facility or at a provider site (wherever services are rendered) requiring medical treatment more than first aid (First aid includes assessing a condition, cleaning a wound, applying topical medications, and applying simple bandages)
|Medication /treatment errors causing severe or potentially severe harm or distress to the member
|Medication/treatment errors not resulting in severe or potentially severe harm or distress to the member
|Adverse reactions to medication/treatment causing severe or potentially severe harm or distress to member (NMS, etc.)
|Adverse reactions to medication/treatment of a moderate or minor nature
|Any time emergency services (fire department, police, EMS, etc.) are summoned to a facility for any reason, such as fire setting, property damage, commitment of a crime, etc.
|Fire setting or property damage at a facility that does not result in summoning emergency services but does require immediate action or repairs to ensure member safety. False alarms are not reportable.
|Any condition that results in temporary closure of a facility, regardless of whether or not a Carelon member is affected by the closure.
|Possession of a deadly weapon and the threat of use of the weapon by member while in any facility, at a provider site, or wherever services are rendered
|Outbreak of a serious communicable disease, regardless of whether or not a Carelon member is present at the time of the notification.
|ANY real or threatened litigation in a case against Carelon or a provider involving a Carelon member/family
|Any real or threatened litigation against a provider not involving a Carelon member/family
|Restraint while in a facility or at a provider site (or wherever services are rendered) that requires serious medical treatment (urgent/emergent care, such as Emergency Department or Urgent Care visit) OR restraint that is unauthorized/used improperly/applied incorrectly. A restraint not approved in the individual support plan or one that is not a part of an agency’s emergency restraint procedure is considered unauthorized.
|All other restraints of any kind, even if the result of the restraint requires minor or no medical treatment
|Self-Injurious Behavior that occurs at a provider site (or wherever services are rendered) and is potentially life threatening or requires serious medical treatment (urgent/emergent care, such as Emergency Department or Urgent Care visit)
|Self-Injurious Behavior that occurs at a provider site (or wherever services are rendered) requiring medical treatment more than first aid (First aid includes assessing a condition, cleaning a wound, applying topical medications, and applying simple bandages)
Or, SIB that demonstrates a new behavioral pattern of concern
|An occurrence that involves contact with the media: presence or inquiry by newspaper, news station, media outlet, etc. with the possibility that a public communication will be distributed.
If you are in doubt that a critical incident has occurred, please notify the Carelon Risk Management Department so that the information can be reviewed.