N.M. Admin. Code § 8.308.21.13 - INCIDENT MANAGEMENT

Critical incident reporting and management is considered part of ongoing quality management. Critical incident reporting and analysis of critical incident data helps to identify causes of adverse events in critical care and areas of focus for implementation of preventative strategies.

A. MCO incident management principles: The implementation of incident management practices and effective incident reporting processes as described in the medicaid managed care services agreement or the managed care policy manual are based on the following MAD MCO principles:

(1) a member is expected to receive home and community based services free of abuse, neglect, and exploitation;

(2) training addresses the response to and the report of to include the documentation of a critical incident;

(3) a member, his or her authorized representative will receive information on his or her MCO incident reporting process; and

(4) good faith incident reporting of or the allegation of abuse, neglect or exploitation is free from any form of retaliation.

B. Reportable incidents:

(1) The MCO shall ensure that any person having reasonable cause to believe an incapacitated adult member is being abused, neglected, or exploited must immediately report that information.

(2) The MCO shall develop and provide training covering the MCO's procedures for reporting a critical incident to all subcontracted individual providers, provider agencies, and its members who are receiving self-directed services, to include his or her employees.

(3) The MCO shall comply with all statewide reporting requirements for any incident involving a member receiving a MAD covered home and community based service.

(4) A community agency providing home and community based services is required to report critical incident involving a MCO member, including:

(a) the abuse of him or her;

(b) the neglect of him or her;

(c) the exploitation of him or her;

(d) any incident involving his or her utilization of emergency services;

(e) the hospitalization of him or her;

(f) his or her involvement with law enforcement;

(g) his or her exposure to or the potential of exposure to environmental hazards that compromise his or her health and safety; and

(h) the death of the member.

(5) The MCO shall provide, coordinate, or both, intervention and shall follow up upon the receipt of an incident report that demonstrates the health and safety of its member is in jeopardy.

Notes

N.M. Admin. Code § 8.308.21.13

8.308.21.13 NMAC - N, 1-1-14, Adopted by New Mexico Register, Volume XXIX, Issue 08, April 24, 2018, eff. 5/1/2018