risk management roles for administrative entities …...pennsylvania department of human services...

Pennsylvania Department of Human ServicesOffice of Developmental Programs

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Course Number C-002

1Risk Management Roles for Administrative Entities and Providers


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Certificates of Achievement will be available to Administrative Entity staff, Providers, Supports Coordinators, and SC Supervisors after completing all course requirements. Please view and then save or print your certificate in order to receive credit for this course.

For SCs and SC Supervisors, course requirements include successful completion of a pre‐test and post‐test.

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Hello, my name is Frank Schweigert. Welcome to the course Risk Management Roles for Administrative Entities and Providers.

I am a Training Manager with The Columbus Organization and will be presenting this training on the behalf of the Office of Developmental Programs.

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The primary objective of this training is to create and support a culture of safety that is reflected in all documented information, including the ISP, ISP Monitoring, Incident Management Reports, and Service Notes. Integral to this culture of safety is ensuring that the recognition, assessment and mitigation of risks is a role of the entire team and those who help to manage and fund the supports and services provided.

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This training is an extension of the SC Role In Mitigating Risk training, focusing on the role of the County, Administrative Entity and Service Providers and their shared responsibility with the Supports Coordinator to recognize and mitigate risk.

The intent of this webcast is to support the common understanding of the critical importance for the team to identify and mitigate risk for the people we serve. The funding status of the individual (waiver funded or non‐waiver funded) does not change the role or responsibility of the AE or County. In this presentation references to the AE or County are inclusive of both roles.

It is recommended that you view the Foundations of Recognizing and Mitigating Risk webcast and the SC Role in Mitigating Risk webcast before viewing this webcast. Both are in the same location where you accessed this webcast.

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These are the definitions of Risk, Risk Factors and Mitigation as stated in the Chapter 51 Regulations.

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Previous trainings identified the importance of choice in assuring that the choices the individual makes are informed, including:

• The potential risks are recognized

• The potential consequences of taking the risks are understood

• The alternatives that are available that could reduce the risk

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When an individual's health and safety are at risk, it is everyone's responsibility to seek risk‐reducing alternatives that may be more appealing (less restrictive/less intrusive) to the person. Instead of using choice as an excuse to do nothing on the individual's behalf, the SC, team, and others involved in the person's life should offer supports that allow that individual to continue to participate in activities that are important to them while concurrently reducing the level of risk.

There are circumstances where a person may choose to continue to engage in risky behavior or refuse to accept support to address specific risk factors. This choice does not end the responsibility of the SC or the team to continue to support the person to identify, understand, and encourage alternative solutions that would reduce the level of risk in the future.

At times, even if the person fully understands the risk and potential consequences, the person may choose to continue to engage in the risky behavior. This could be because the alternatives offered seem more restrictive or appear to interfere with their ability to participate in activities with their friends or community. When this happens, our role must be to look for other risk‐reducing alternatives that may be more appealing (less restrictive) to the person or offer supports that allow them to continue to participate in those activities that are important to them.

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When working with the team, brainstorming, making decisions, and creating mitigation plans to keep someone safe and healthy, we also need to ensure that we are planning for the least restrictive alternative environment for the person to choose from, that safely and effectively address their needs and preferences. We also need to ensure that the available alternative environments are in an integrated setting that enables the person with a disability to interact with people who do not also have disabilities. This not only supports ODP’s Mission and Everyday Lives, but it is also a requirement of CMS.

Taking risks can enhance the quality of an individual’s life as risk taking may lead to new experiences and learning. This could include things such as taking a painting class, joining a social club, or even just choosing what to buy. We need to keep in mind the value of taking risks as we are planning with the individual, family, and other team members.

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The Risk Mitigation Cycle graphic is a tool to help:

• Raise awareness to recognize potential risk factors

• Use critical thinking to identify other potentially related risk factors

• Develop, with the team, creative solutions to reduce the level of risk.

Effective risk identification, assessment and mitigation is a responsibility of the entire team, and requires their combined expertise and resources throughout the entire cycle.

In the following slides, the role of the Service Provider and the Administrative Entity/County is to assure that potential risks are not only identified and assessed, but that the strategies are appropriate, implemented consistently and evaluated effectively. First though, we’ll quickly review a couple key elements in identifying and addressing risk.

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The severity of risk is broken down into two basic categories; Imminent and Non‐urgent.

Imminent risk was defined as a risk that, requires immediate action and if not addressed, injury, whether it is physical harm, exploitation, or emotional abuse, is very likely to happen, and very soon (minutes, hours or possibly the next day or two). If there is an imminent risk, there is a need to act immediately in order to protect the person from injury and when necessary taking action to enlist the support of emergency services first.

Non‐urgent risk was defined as a risk that, if not addressed, injury is not likely to occur immediately, giving at least a little time to better assess the situation, seek out additional supports and develop a longer term plan to reduce the potential for injury.

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This graphic is a tool to assist in defining the actions of the teams.

The Red area represents imminent risks, those risks that are likely to happen at any moment and require the immediate actions of those present to protect the health, safety, and welfare of the individual.

The Orange area includes the risks that are severe but not necessarily immediate in nature. These risks still may require some immediate actions to reduce or eliminate the risk from becoming imminent, but will also allow for the team to develop a plan to address the risk over time.

The Yellow area is designated for risks which are immediate but not severe in their nature to cause injury to the individual. Risks in this area require action to reduce, eliminate or manage risks and avert the escalation of the risk to a more serious level.

The Green area includes the less severe risks that are not likely to occur soon, but are still a concern. These risks allow the team to plan and implement strategies designed to avoid or reduce the impact of the future adverse events (or prevent the adverse event from having a more severe impact.)

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Individually, some risk factors may not be considered significant, but consideration must be given to the potential impact of Person, Place and Time contributing to the severity of risk. When variables such as the attributes or behaviors of the person (Person), a physical place or circumstance (Place), or the occurrence of other factors coincide at the same time (Time) are also considered, it could result in an increased level of risk and increase the likelihood of becoming an imminent risk to the person’s health and safety.

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So let’s look at one example to demonstrate how the combination of Person, Place, and Time can suddenly turn lower potential risks into a number of imminent risks.

Peter is in his late 40’s and lives with his elderly, but healthy mother. He takes a lot of pride in being independent and helping his mother around the house. Peter has been diagnosed with high blood pressure, but it is well controlled with medication and diet. Peter’s mom helps to ensure he takes the medicine regularly and that most of his meals are not high in fat or salt. However, when Peter goes for walks or to the mall, he loves to buy food items that tend to have a higher salt and fat content. Recently he started a new Supported Employment job at a local sports store at the mall and he has a new job coach, Tanya.

In this example there are several things that you may have identified as potential risks, each of them not necessarily immediate or severe.

• Elderly mother

• High blood pressure

• A diet that does not always help to control his blood pressure

Having a new job coach, who is just beginning to learn about Peter and how to support him in the job may not be a risk, per se, but is also something the team is aware of.

One day, his SC gets a call from the job coach. Tayna reports that while Peter is working hard at learning his new job, he is in risk of losing it because of hygiene issues and because Peter seems to be distracted during work. The SC goes to visit Peter at his home. Upon arriving, the SC notices that Peter’s face appears flushed and he is a bit unsteady on his feet. The SC further observes that the house is not as tidy as it's been during previous visits. There is a large stack of unopened mail by the door and none of the lights in the house are on. While talking to Peter, the SC discovers that Peter’s mom fell and broke her hip a couple months ago and has been in a rehabilitation facility. When asked by the SC why Peter didn’t let anyone know, he stated “I can take care of myself and my mom.” After a little more discussion, the SC discovers that the house has no electricity, gas, or water because the bills haven’t been paid. There are no fresh groceries in the house and Peter has been eating most of his meals at the mall or the local convenience store. In addition, Peter has not refilled or taken his blood pressure medication for well over a month.

Each of those risks identified earlier, may not have been an immediate or severe risk by themselves, but the combination of Peter’s desire to be independent and his high blood pressure (Person), his mother’s fall and hospitalization (Place) and the turning off of his utilities and water (Time) have combined to create a number of imminent risks for Peter’s health and safety.

While the SC or the team may not have been able to predict that the mother might fall, considering the possibilities of each of these risks can be the difference between safe management and crisis should one or more happen at the same time. This could have allowed them time and thoughtful consideration to develop a plan with Peter and his mother that at the least, could have lessened the likelihood of any of them becoming an imminent risk.

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Anyone who is familiar with the person or a particular situation will likely have some experience or knowledge they can share to help ensure potential risks and risk factors are recognized by the team. As a member of the team or as a reviewer of the plan, sharing what you know with the SC and the other team members is critical to ensuring that any potential risks to the health and safety of the individual being supported are identified and addressed.

The ISP, ISP Monitoring Tool, Incident Management Reports, and Service Notes were highlighted in the SC Training as areas to record information learned about potential risks. But these documents can also be tools to help others involved in the process to identify additional potential risks that may have been overlooked. While we will look at each of these documents individually, in many cases, especially in regard to mitigating risk, these documents can be closely linked, each potentially containing important information that must be considered.

So let’s take a look each of these documents and how Service Providers and the AE or County can help to ensure that not only are the potential risks identified, but also appropriately addressed by the team.

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The ISP is a collaborative document, developed by the team, that contains a great wealth of information to support the individual to receive the services and supports that they may need. Potential risks and risk factors that could impact their lives should be included in that information.

Sections in the ISP such as Important To, Health and Safety, Health Promotion, and Functional Information are specific sections that are identified as possible areas for identifying these potential risk factors, but additional risk factors could be identified almost anywhere in the plan, including Allergies, Psychosocial Information, Cooking/ Appliance Use, Reasons for Intensive Staffing, Communication, Financial Management, and the list goes on.

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As a service provider, part of your role in the ISP process is to assist in gathering the information to be included in the plan. Each member of the team should ensure that any potential risk factors related to the information provided are identified, so that they can be reviewed and assessed by the entire team, taking into account any other related risk factors that may also exist. It is the responsibility of the provider to assist the team in recognizing and addressing risk, and if more than one risk factor exists that could elevate the severity of the risk to the individual.

Then as the team begins to identify the Outcomes and Outcome Actions, service providers help to ensure that the relevant risk factors are identified in the Concerns or Assessments section, that the Actions Needed section includes any plans to mitigate the risk and that the mitigation plan is respectful of the preferences of the individual. Finally, when a new risk is identified, or discovered, be sure that this new learning is recorded and communicated to the team.

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Depending on the size and organization of the AE/County, your role in the risk mitigation process can take many forms. For now, we will focus on the role of ISP Review and Authorization of Services.

AE/County authorization of the services identified in the ISP indicates that the services and frequency identified are supported by the content of the entire plan and appropriate to the needs of the individual. It is also an affirmation by the AE/County that the Action Plans and services are not only designed to meet the individual’ s needs but also ensures their health and safety, including identification and addressing of any risk mitigation plans using the least restrictive alternatives.

While AE/County staff may or may not be an active member of the team, they bring a wealth of knowledge and experience. During the AE/County’s review of the ISP, additional risks or risk factors may be recognized that the team may not have been aware of. The AE/County should communicate this new information to the team, requesting any revisions that may need to be included in the ISP, so that all risks are identified and mitigated.

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Supports Coordinators are required to conduct periodic monitoring to help assure the health and safety of the individual and to ensure the implementation and effectiveness of the services identified in the approved ISP. “The outcome of the monitoring process is to identify, document and recommend resolution to issues or comments resulting from the standards associated with the monitoring process.”

SC monitoring is not only a review of the current implementation of the ISP, including any risk mitigation plans, but is also an opportunity to document potential risks that were not previously recognized. Once identified they will need to be evaluated and if necessary, mitigation plans revised or developed.

As mandated reporters, the AE/County, SCs, and service providers should follow all steps in reporting and responding to suspected abuse, neglect, and exploitation. Actions may be instituted by ODP certified investigators, Adult Protective Services, Child Protective Services, Older Adult Protective Services, law enforcement, and other entities.

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During an ISP Monitoring, when an imminent or non‐urgent risk is newly identified, SCs are to record this on the Monitoring form within the “Issues” section. If the risk is imminent, not only is there a responsibility of the SC and service provider to take immediate action to protect the health and safety of the individual, but the SCO is required to report these imminent risks to the AE and ODP.

The documentation of a non‐urgent risk as an “Issue”, recognizes the risk and the need for timely action by the team to coordinate the development of a mitigation plan to address the risk.

The SC can use the “Comments” to document the effectiveness of existing mitigation plans. The “Comments” can also document any new learning that may have resulted in the implementation of the mitigation plan or to document suggested revisions to the mitigation plan based on this new learning.

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During the monitoring process, when an Imminent risk is identified, the role of the Service Provider is to assist and support the SC in taking the immediate actions necessary to protect the health and safety of the individual and then work with the SC, AE and ODP to develop a mitigation plan to ensure their continued safety.

If a non‐urgent risk is identified as an “Issue”, collecting any related information to assist the team in evaluating the level of risk and development of an appropriate mitigation plan is critical. The service provider can assist in the collection of this information in order to help ensure future services and supports are designed to protect the health and safety of the individual.

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When reviewing submitted ISP Monitoring forms, the AE staff should review and assure that immediate action was taken (and reported by the SCO ) for any imminent risks and that appropriate actions were taken or are in process for any documented “Issues” related to risks. The AE should also review any related Service Notes or ISP revisions that may be referenced in the Monitoring form and provide guidance to the team on additional risks or potential complications that may not have been initially recognized and provide feedback related to the identified strategies to mitigate the risk.

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When it comes to Incident Management reports, unfortunately many of these can result from a change in circumstances that introduces a new, unanticipated risk, the team not recognizing or effectively addressing existing risks, or the unanticipated occurrence of several risk factors at the same time that increased the severity of potential harm to the individual.

Despite even the best efforts of the team, sometimes bad things can happen and the information contained in the Incident Management Report can not only be used by the team to minimize the potential risk of the incident re‐occurring in the future, but can also be used to identify other potential risks, that up to this point, may have gone unrecognized.

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Each Incident Management Report documents and reports what took place and how the particular incident was responded to. For many Incident Reports, the first step is to focus on the specific event or conditions and respond with new strategies or policies designed to prevent that specific event from happening again.

However, to fully take advantage of any learning that can result, the team must also look closely at what additional risk factors may have been present and contributed to the event and what other information they may need and who might have that information.

Having done this, the SC, AE/County, and Service Provider can be more proactive in developing a long range mitigation strategy with the individual that addresses the main risk factors as well as other potentially contributing risk factors.

The SC, AE/County and service provider should also consider whether the conditions that existed in this situation and the mitigation strategies developed may also apply to other individuals who may be in similar situations and face similar risks where the implementation of these strategies could help to prevent future incidents.

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In the SC trainings, the Service Notes were identified as a place for the SC to document additional information that may be related to an identified risk, that may not have been included in an Incident Management report, an ISP Monitoring, or the most recent version of the ISP. Within the training, the importance of creating a “trail” between these related documents was stressed. In the beginning of the note, this trail can be accomplished by referencing back to the original risk that was identified with a short phrase and the date the risk was first identified.

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It is equally important for the service provider to create a similar trail within the documentation they keep, such as daily service notes or monthly progress notes. By clearly identifying the risk and linking information from each type of documentation, it makes it easier to locate and share the actions taken and learning that may occur related to the risk.

The information from daily service notes can then be summarized in the monthly progress reports and incorporated into future revisions of the ISP or as part of the follow‐up to an incident report.

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The skills needed to successfully recognize and assess risks, develop and implement effective mitigation strategies, and evaluate the success of these strategies in mitigating or eliminating the risk requires the combined expertise and involvement of the entire team.

In the next section of this training, you will have the opportunity to practice some of these skills with some scenarios based on real situations in Pennsylvania.

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This webcast has been developed and produced for the Pennsylvania Department of

Human Services, Office of Developmental Programs by The Columbus Organization.

Thank you for participating in this lesson.

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risk management roles for administrative entities …...pennsylvania department of human services...

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