441—90.8 (249A) Provider requirements.
	 90.8(1) Incident reporting.
	  a.   	 When a major incident occurs during the provision of case management services:
	 (1) 	 The case management provider shall notify the following persons of the incident by the end of the next calendar day after the incident:
	  1. 	 The case management supervisor.
	  2. 	 The member’s legally authorized representative.
	 (2) 	 By the end of the next calendar day after the incident, the case manager who observed the incident shall also report as much information as is known about the incident to the department’s bureau of long-term care either:
	  1. 	 By direct data entry into the Iowa Medicaid Provider Access System, or
	  2. 	 By faxing or mailing Form 470-4698, Critical Incident Report, according to the directions on the form.
	 (3) 	 The following information shall be reported:
	  1. 	 The name of the member involved.
	  2. 	 The date and time the incident occurred.
	  3. 	 A description of the incident.
	  4. 	 The names of all case management staff and others who were present at the time of the incident or who responded after becoming aware of the incident. The confidentiality of other members or nonmembers who were present must be maintained by the use of initials or other means.
	  5. 	 The action that the case manager took to manage the incident.
	  6. 	 The resolution of or follow-up to the incident.
	  7. 	 The date the report is made and the handwritten or electronic signature of the person making the report.
	 (4) 	 The case manager shall monitor the situation as required in paragraph 90.5(1)“d” to ensure the member’s needs continue to be met. Submission of the initial report will generate a workflow in the Individualized Services Information System (ISIS) for follow-up by the case manager.
	 (5) 	 The case managment provider shall maintain the completed report in a centralized file, with a notation in the member’s file.
	  b.   	 When an incident report for a major incident is received from any provider, the case manager shall monitor the situation as required in paragraph 90.5(1)“d” to ensure the member’s needs continue to be met.
	  c.   	 When any major incident occurs, the case manager shall reevaluate the risk factors identified in the risk assessment portion of the comprehensive assessment as required in paragraph 90.5(1)“a” in order to ensure the continued health, safety, and welfare of the member.
	 90.8(2) Emergency coverage. Effective October 1, 2009, a provider of case management shall have an on-call system to ensure that, in the event of an emergency, members have access to a case manager 24 hours per day, including weekends and holidays. Expectations and parameters for emergency coverage are as follows:
	  a.   	 The emergency on-call system should be one component of the member’s individualized crisis intervention plan and should not be the only emergency resource for the member. The system should not replace emergency services such as 911, crisis intervention lines, or emergency services from provider agencies.
	  b.   	 The case manager should never provide direct service, but rather is expected to arrange and coordinate services to make sure the member is safe.
	  c.   	 Case management providers may screen calls to identify nonemergency calls that can wait until regular business hours or to divert calls to other resources when appropriate.
	  d.   	 Time spent on responding to calls is billable time for the case management provider. Overhead costs may be included in the case management rate as an indirect cost.
	 90.8(3) Quality assurance. Providers shall cooperate with quality assurance activities conducted by the Iowa Medicaid enterprise to ensure the health, safety, and welfare of Medicaid members. These activities may include, but are not limited to:
	  a.   	 Postpayment reviews of case management services,
	  b.   	 Review of incident reports,
	  c.   	 Review of reports of abuse or neglect, and
	  d.   	 Technical assistance in determining the need for service.
[ARC 7957B, IAB 7/15/09, effective 7/1/09]