A Critical Incident is defined by the State Medicaid Contract (Article 9.10) as “an occurrence involving the care, supervision, or actions involving a member that is adverse in nature or has the potential to have an adverse impact on the health, safety, and welfare of the member or others. Critical Incidents also include situations occurring with staff or individuals or affecting the operations of a facility/institution/school.”

Horizon NJ Health is required to:

• Train staff and contracted FIDE-SNP providers on identifying, reporting, investigating and monitoring Critical Incidents.
• Develop policies and implement procedures for Critical Incident reporting.
• Track, review and analyze Critical Incidents to identify and address potential and actual health and safety issues.

Report a Critical Incident

Providers are responsible for reporting Critical Incidents to Horizon NJ Health, within 1 Business Day of discovery by faxing the Critical Incident Reporting Guide to 1-609-583-3003.

Types of Critical Incidents

1. Unexpected death of a member

2. Media involvement or the potential for media involvement

3. Physical abuse (including seclusion and restraints both physical and chemical)

4. Psychological/verbal abuse

5. Sexual abuse and/or suspected sexual abuse

6. Fall resulting in the need for medical treatment

7. Medical emergency resulting in the need for medical treatment

8. Medication error resulting in serious consequences

9. Psychiatric emergency resulting in need for medical treatment

10. Severe injury resulting in the need for medical treatment

11. Suicide attempt resulting in the need for medical attention

12. Neglect/mistreatment, caregiver (paid or unpaid)

13. Neglect/mistreatment, self

14. Neglect/mistreatment, other

15. Exploitation, financial

16. Exploitation, theft

17. Exploitation, destruction of property

18. Exploitation, other

19. Theft with law enforcement involvement

20. Failure of member's Back-up Plan

21. Elopement/wandering from home or facility

22. Inaccessible for initial/on-site meeting

23. Unable to Contact

24. Inappropriate or unprofessional conduct by a provider involving member

25. Cancellation of utilities

26. Eviction/loss of home

27. Facility closure, with direct impact to member's health and welfare

28. Natural disaster, with direct impact to member's health and welfare

29. Operational Breakdown

30. Other