Incident Reporting Policy & Procedure

Common Operational Procedures > Incident Reporting Policy & Procedure

Policy authorised by Board of Management 6 March 2020

Procedure authorised by Chief Executive Officer

Revised Procedure Date: 13 November 2020

Policy Statement

Kyeema Support Services ensures that all incidents are acknowledged, investigated, responded to, well managed and learned from.

This policy supports Kyeema Support Services to apply Standard 2: Governance and Operational Management of the NDIS Practice Standards.

Who does this apply to?

This policy applies to all Kyeema workers and their incident reporting requirements, including Occupational Health & Safety (OH&S) incidents whether or not they are participant-related.

Related legislation and policy

The National Disability Insurance Scheme Act 2013

NDIS (Incident Management and Reportable Incidents) Rules 2018

DHHS Client Incident Management System (CIMS) 2019

Occupational Health and Safety Act 2004

Workplace Injury Rehabilitation and Compensation Act 2013

What is reportable conduct under the Reportable Conduct Scheme –Commission for Children and Young People Victoria https://ccyp.vic.gov.au/reportable-conduct-scheme/

Privacy Act 1988

Child Wellbeing and Safety Act 2005

Factsheet: Safety screening requirements from 1 July 2019 DHHS – July 2019

Definitions

Workers include employees, contractors and volunteers

Incident

An incident is defined as an act, omission, event or circumstance.

It may mean any of the following:

• Acts, omissions, events or circumstances that occur in connection with providing NDIS supports or services to a person with disability and have, or could have, caused harm to the person with disability

• Acts by a person with disability that occur in connection with providing NDIS supports or services to the person with disability and which have caused serious harm, or a risk of serious harm, to another person

• Reportable incidents that have or are alleged to have occurred in connection with providing NDIS supports or services to a person with disability

Near Misses are things that could have caused harm but did not.

Hazard is a source of potential harm to people or a situation with potential to cause injury, loss to property or equipment or damage to the natural environment.

Reportable Incidents are serious incidents or allegations, which result in harm to a participant. Reportable incidents (including allegations) include:

• the death of a participant

• serious injury of a participant

• abuse or neglect of a participant

• unlawful sexual or physical contact with, or assault of, a participant

• sexual misconduct committed against, or in the presence of, a participant, including grooming of the participant for sexual activity

• unauthorised use of a restrictive practice in relation to a participant.

Other relevant authority incident definitions refer to Kyeema Incident Reporting Chart CCF-31

In-house incident reporting procedure for workers (employees, contractors and volunteers)

When an allegation or incident occurs the worker follows the in-house incident management process. All incidents and allegations are to be reported (refer to the Incident Reporting for Support Workers Poster CCF-30). Allegations of abuse must be reported immediately.

• Worker provides immediate response to ensure the safety and wellbeing of the impacted person

• Contact police/emergency services if required

• If relevant, protect any evidence for use in possible further investigation

• Report incident to manager/team leader

• Complete CCF-65 Participant Incident Report Form for Support Workers

• Report injuries in the Register of Injuries book present at all sites

• Support workers report incident on Carelink shift notes

• If relevant, fill out the Hazard and Near Miss Alert Form SF-10 with manager/team leader

Reporting procedure by team leaders/manager

Initially incidents are recorded and managed through the in-house incident management system using relevant procedures and forms (Participant Incident Report Form for Support Workers CCF-65). Reportable incidents are managed and responded to by the manager/team leader according to their severity and reported externally to relevant authorities as required.

(Refer to Kyeema Incident Reporting Chart CCF-31 for clarification)

• Provide immediate response to ensure the safety and wellbeing of the impacted person and workers

• Police/emergency services if necessary

• Notify impacted persons support person and/or family

• Complete SF-10 with relevant workers

• Complete page 4 of CCF-65 Participant Incident Report Form for Support Workers

• Document incident on Incident Report Database (k-drive\general items for all staff\incidents)

• Document restrictive practices on Restrictive Practices Register (k-drive\general items for all staff\behaviour support and restrictive practices)

• Complete Investigation Checklist CCF-05

• Determine if the incident is reportable and proceed to follow procedure for the relevant authority such as:

o Police – mandatory reporting of child protection

o NDIS Commission (NDIS participants) online reporting, CCF-29

o DHHS Critical Incident Management System CIMS (non NDIS participants) online reporting

o Coroner/police – report a death

o Child Safety Reporting DHHS, CCF-20, CCF-38

o Commission for Children and Young People (CCYP) online reporting for child safety allegations against a worker(18 yrs up)

o OH&S incidents SF-48, SF-10, S-11 poster

o WorkSafe online reporting, SF-48

o Office of the Australian Information Commissioner (OAIC) online reporting for confidentiality/privacy data breaches

o Transport Accident Commission online reporting for serious incidents

o Disability Worker Exclusion Scheme (DWES) for adverse findings arising from a police check

o Incidents involving allegations of worker to participant assault or unexplained injuries CEO/Manager to use the Investigations Checklist CCF-05

Some incidents may have to be reported to more than one relevant authority.

Relevant authority reporting requirements (refer to Kyeema Incident Reporting Chart CCF-31)

NDIS Commission (reported by CEO/Manager)

Most reportable incidents must be:

• notified to the NDIS Commission (Immediate Notification Form available from the online Portal) within 24 hours, and

• followed up with a detailed report about the incident and actions taken in response within 5 business days.

The unauthorised use of restrictive practice must be:

• notified to the NDIS Commission within 5 business days, but

• reported within 24 hours if there is harm to a participant.

A final report may also be required within 60 business days of submitting the 5 day report. The NDIS Commission will advise you whether a final report is required.

Resources:

• NDIS Process for Notification of Reportable Incidents for Team Leaders & Managers Flowchart CCF-29

• NDIS Commission Portal – My Reportable Incidents

https://www.ndiscommission.gov.au/providers/provider-registration/ndis-commission-portal

Outside of business hours advise the NDIS Commission via email to reportableincidents@ndiscommission.gov.au with an email that includes:

• The steps taken to complete the authorised notification form and the presenting issue

• The name of the impacted person

• Describe the immediate response and step taken to ensure the impacted person was safe

• Brief description of the reportable incident

• Whether other authorities, such as the police, were notified

Confirmed case of COVID-19 report to:

• Notification of event form - COVID-19 (registered providers) https://www.ndiscommission.gov.au/providers/notice-changes-events/notification-covid-19

DHHS CIMS (Critical Incident Management System) (reported by CEO/Manager)

You will need to report via CIMS for any non-NDIS participants.

Major and non-major impact incidents require the completion and submission of a client incident report to the designated divisional office within three business days of the incident occurring or of the service provider becoming aware of the incident (Figure 1). All major impact incidents must be subject to either an investigation and/or a review led by the service provider (see Kyeema Incident Reporting Chart CCF–31 for definitions of major and non-major impact incidents)

• Critical Incident Management System (CIMS) Incident Reporting https://cims.vic.gov.au/#/introduction

• Client Incident Management Summary Guide (3)

https://providers.dhhs.vic.gov.au/client-incident-management-summary-guide-word

COVID-19 confirmed diagnosis notify the Department of Health and Human Services DRRG by email DRRG@dhhs.vic.gov.au

Police

Where a reportable incident may constitute a criminal offence or if police attendance is necessary to ensure the safety of those involved in the incident, the incident must be reported immediately to the Victoria Police on 000

Coroner

A ‘reportable death’ to the Coroner includes deaths that appear to be unexpected, unnatural or violent or to have resulted, directly or indirectly, from accident or injury. http://www.coronerscourt.vic.gov.au/.

Child Safe Reporting (reported by CEO/Manager)

Where a person believes on reasonable grounds that the reportable incident has child protection implications, NDIS providers will be required to comply with mandatory child protection reporting requirements.

Child (0-17 years) abuse incidents or allegations are reported to

• Police 000

• DHHS Child Protection ph. 1800 075 599 (AH 131278)

§ Child Safe Incident Report Form CCF-20

§ Child Safety Reporting Process Flowchart CCF-38

• NDIS Commission if the child is an NDIS participant

Child safety allegations made against a worker/volunteer (18 years or older) reportable conduct includes allegations against workers or volunteers of child abuse and misconduct involving children. For example, reportable conduct includes sexual misconduct or offences, grooming, ‘sexting’, inappropriate physical contact with a child or other conduct that crosses professional boundaries concerning children.

Report to:

• Police 000

• Commission for Children and Young People (CCYP)

§ Reportable Conduct Scheme Notification form within 3 business days (reported by CEO) and a 30 day follow up report

§ Notify and update reportable allegations https://ccyp.vic.gov.au/reportable-conduct-scheme/notify-and-update/

§ What is reportable conduct? https://ccyp.vic.gov.au/child-safety/resources/reportable-conduct-scheme-information-sheets#TOC-2

• NDIS Commission if the child is an NDIS participant

OH&S

For incidents not reportable to WorkSafe, workers are to:

• Fill in Register of Injuries book present at all work sites

• Report incident on Incidents Report Register

• Report that Hazard SF-11

• Complete Hazard and Near Miss Alert form SF-10

• Accident Injury Reporting form –workers (employees, volunteers, contractors) SF-48

• NDIS Commission for NDIS participant

• DHHS CIMS for non NDIS participant

WorkSafe Victoria (reported by CEO/Manager)

Refer to Worker Injury Reporting and Notifiable Incidents Procedure

• Worker Injury Reporting and Notifiable Incidents Procedure

§ Confirm incident reportable

§ Ensure incident scene is not disturbed until an inspector arrives

§ Notify WorkSafe immediately on 132360

§ Report the incident in writing to WorkSafe within 48 hrs

§ Store a copy of the incident notification form securely

• Issue Resolution Flowchart SF-06

• WorkSafe incidents online reporting notification form: https://prod.wsvdigital.com.au/sites/default/files/2019-01/FOR-Incident-notification-form-2019-01.pdf

How to report a Confirmed COVID-19 Diagnosis

• When to notify WorkSafe

Management must notify WorkSafe immediately after becoming aware that:

§ an employee, independent contractor, employee of the independent contractor or self-employed person has received a confirmed diagnosis of coronavirus (COVID-19) and;

§ the employee, independent contractor, employee of the independent contractor or self-employed person has attended the workplace within the relevant infection period.

• Notify WorkSafe immediately

Option A: Complete the COVID-19 reporting form www.worksafe.vic.gov.au/notifiable-incidents-involving-coronavirus-covid-19

Option B: Call Worksafe on 13 23 60

WorkSafe will then record details of your incident and send you an email with a unique link for you to complete the last stage of notifying us of the full details in writing. It is mandatory that you complete the full details in writing within 48 hours. Call 13 23 60 if unsure.

• Report the incident within 48 hours

Once you have completed and submitted the online incident notification form, you will receive a confirmation email with a copy of your records.

• If having trouble completing the online form

If you are having trouble completing the online incident notification form, download a print copy of the incident notification form, and email the completed form to: info@worksafe.vic.gov.au

Worksafe incident notification form:

https://www.worksafe.vic.gov.au/resources/incident-notification-form

Source: https://www.worksafe.vic.gov.au/report-confirmed-covid-19-diagnosis

Office of the Australian Information Commissioner (reported by CEO/Manager)

• Report incident on Incidents Report Register

• Breach of Confidentiality or Privacy Procedure

• Notifiable Data Breach Form (NDB) https://forms.business.gov.au/smartforms/landing.htm?formCode=OAIC-NDB

• NDIS Commission for NDIS participant

• DHHS CIMS for non NDIS participant

Disability Worker Exclusion Scheme (DWES) Notify the DWES Unit of adverse findings arising out of a national police check or an international police check. Adverse findings are those which indicate a worker has been found guilty of any offence, regardless of whether they are imprisoned, which:

• involves bodily harm

• involves violence or threats of violence

• is of a sexual nature

• involves dishonesty

• involves neglect of a person in their care

• is either a category 1 or category 2 NDIS exclusion offence

Incidents of worker misconduct will be notified to the NDIS Quality and Safeguards Commission

Transport Accident Commission (TAC)

• Report incident on Incidents Report Register

• Complete the Serious Incident Form http://www.tac.vic.gov.au/providers/for-service-providers/for-disability-service-providers/serious-incident-form

• The form is to be submitted to the TAC within 24 hours of the Provider becoming aware of an incident or allegation.

Funds in Court and Commonwealth Continuity of Support participants

• Report incident on Incidents Report Register

• Report critical incidents to emergency services and family

Vehicle Incidents

• use SF-13 and report incident to reception

Reporting responsibilities

Responsibility for the implementation of this procedure belongs to the CEO, all managers, team leaders, on-call workers and support workers. It is the managers responsibility to ensure that workers are supported to report incidents and that there are no negative consequences in doing so. All online reporting is the responsibility of the CEO/Manager

Record keeping

All documentation relating to the incident or alleged incident (both paper and electronic) is to be kept in a safe and secure place. The Incident Register (K:\General Items for All Staff\Data Bases\Incident Report Database.mdb) must be updated within 24 hours of an incident or alleged incident occurring. Hard copies of reports are to be filed in the participants file. Records of each reportable incident must be kept for seven years.

All restrictive practices are documented on the Restrictive Practices Register (k-drive\general items for all staff\behaviour support and restrictive practices) and the participant file.

These records must be made available to approved quality auditors as part of the audit process and may be used to contribute to NDIS Commission investigations of incidents.

In all cases, you must provide an assessment of:

• the impact on the NDIS participant

• whether the incident could have been prevented

• how the incident was managed and resolved

• what, if any, changes are required to prevent further similar events occurring

• whether other persons or bodies need to be notified.

Save a copy of the Worksafe incident notification form for 5 years

Awareness and training

Information on the incident reporting procedure is available on the QMS, noticeboards and worker training days. Workers are aware of, trained in and comply with the required procedures in relation to incident reporting.

Any significant changes in this policy or process will be advised to workers through the organisation’s intranet and if appropriate, training workshops will be offered.

Complaints

Kyeema service issue complaints refer to Complaints and Feedback Management Policy and Procedure

Complaints about the quality or safety of NDIS supports and services can be made to the NDIS Commission 1800035544

Complaints about the NDIA or participant plans continue to be made to the NDIA or Commonwealth Ombudsman.

Review and Evaluation

The NDIS Commission and/or other relevant authority may take action in response to a reportable/notifiable incident. This may require specified remedial action, carry out an internal investigation about the incident, refer the incident to another body, or engage an expert to investigate and report on the incident.

The CEO/Manager will reflect on the process and decide whether or not corrective action should be taken to improve service quality and delivery of supports and restorative action to repair the relationship with the person with disability.

The CEO will keep the Board of Management informed of any issues relating to critical incidents. Reportable Incidents will be reported to the NDIS Commission and/or other relevant authorities and the Board will be briefed on responses to any incidents that indicate a need for changes to policies or procedures.

Related policy, procedures and documents

Responding to Allegations of Abuse, Neglect and Exploitation Policy

Child Safe Policy

Worker Injury Reporting and Notifiable Incidents Procedure

Privacy and Confidentiality Policy and Procedure

Confidentiality and Notifiable Data Breaches

Accident Injury Reporting Form – workers (employees, volunteer and contractors) SF-48

Hazard and Near Miss Alert Form SF-10

Report a Hazard SF-11

Vehicle Incident Form SF-13

Child Safe Incident Report Form CCF-20

Investigations Checklist CCF-05