MLTSS Critical Incident Reporting

Providers who suspect or have evidence of an MLTSS member experiencing a Critical Incident must report it to Horizon NJ Health within one business day of discovery. Upon discovery of a Critical Incident, providers are to take steps to prevent further harm to members and promptly respond to these members’ needs. These steps may include reporting potential criminal law violations to law enforcement.

**The initial report of a Critical Incident may be submitted verbally, but the verbal report must be followed up by a written report within two business days. **

Examples of a Critical Incident:

  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 of medical treatment
  7. Medical emergency resulting in 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 of 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

Providers who have reported, or have been involved with, an MLTSS member Critical Incident are also required to independently conduct an internal investigation, and submit a summary of their findings to Horizon NJ Health. The report should be submitted no later than 15 calendar days after the date of the incident or discovery of its occurrence. Under extenuating circumstances, but only with the approval of Horizon NJ Health, the summary may be submitted within 30 calendar days after the date of the incident.

To report a Critical Incident to Horizon NJ Health:

  • Call Horizon NJ Health MLTSS Provider Services at 1-855-777-0123, or
  • Fax the Horizon NJ Health Critical Incident Reporting Guide, along with any supporting documentation, to Horizon NJ Health at 1-609-583-3003.
Tikka Attach

MLTSS Member?s Name, Identification Number and Contact Information:

Member Name: DOB:
Member ID: Medicaid ID:
Member Address:
Gender:
Reporting Individual/Agency Contact Information:

Reporting Individual?s Name and Title: Provider Type:
Name of the Reporting Agency:
Reporter?s Phone Number:
Reporter?s Email Address: Today?s Date:
Date the Critical Incident was Discovered:
Date that the Critical Incident Actually Occurred:
Date Horizon NJ Health was notified of Critical Incident:

Primary medical complexity: (check all that apply) q Heart Condition (i.e. CVA, Hypertension, CHF) q Muscular/Skeletal (i.e. Arthritis, Fracture)
q Neurological (i.e. Alzheimer?s, MS, Head Trauma, Quadriplegia, Seizure Disorder) q Infections (i.e. Pneumonia, TB, UTI)
q Psychiatric/Mood (i.e. Anxiety, Depression, Behavioral/Mental Illness, Psych Diagnosis) q Pulmonary (i.e. Emphysema, Asthma, COPD)
q Sensory (i.e. Vision/Hearing Impaired) q Other Diseases (i.e. Renal Failure, Cancer)

Type of critical incident (indicate all that apply):

q Unexpected death of a member
q Media involvement or the potential for media involvement
q Physical abuse (including seclusion and restraints both physical and chemical)
q Psychological/verbal abuse
q Sexual abuse and/or suspected sexual abuse
q Fall resulting in the need of medical treatment
q Medical emergency resulting in need for medical treatment
q Medication error resulting in serious consequences
q Psychiatric emergency resulting in need for medical treatment
q Severe injury resulting in the need of medical treatment
q Suicide attempt resulting in the need for medical attention
q Neglect/mistreatment, caregiver (paid or unpaid)
q Neglect/mistreatment, self
q Neglect/mistreatment, other
q Exploitation, financial

q Exploitation, theft
q Exploitation, destruction of property
q Exploitation, other
q Theft with law enforcement involvement
q Failure of member?s Back-up Plan
q Elopement/wandering from home or facility
q Inaccessible for initial/on-site meeting
q Unable to contact
q Inappropriate or unprofessional conduct by a provider involving member
q Cancellation of utilities
q Eviction/loss of home
q Facility closure, with direct impact to member?s health and welfare
q Natural disaster, with direct impact to member?s health and welfare
q Operational breakdown
q Other (please describe): ______________________________________

Upon discovering a Critical Incident, Horizon NJ Health providers are to promptly take steps
to prevent further harm to members and respond to any emergency needs, which may warrant
contacting local law enforcement, 911/EMS, and/or reporting to appropriate authorities, including
but not limited to:
? The designated County Adult Protective Services (APS) agency: 1-800-792-8820.
? The NJ Office of the Ombudsman for Institutionalized Elderly (OOIE): 1-877-582-6995
? The NJ Child Protection and Permanency ? Child Abuse Hotline: 1-877-652-2873
Additionally, please complete this form in its entirety and fax to the Horizon NJ Health Quality
Management Department along with any supporting documentation to 1-609-583-3003.
The maximum timeframe for a provider to report a Critical Incident to Horizon NJ Health
is one business day from the time the provider discovers or is informed of the incident.

MLTSS Critical Incident Reporting Guide
Provider Services: 1-855-777-0123



Critical incident narrative

Provide a detailed but succinct description of the Critical Incident:

Including:

What was done to immediately ameliorate the issue for the member:

Name of the alleged perpetrator, and his/her relationship to the member:

Location of Incident:

Ways this incident could possibly have been prevented:

Referrals made (indicate all that apply and the date the referral was made):

In addition to reporting Critical incidents to Horizon NJ Health, MLTSS providers remain responsible for adherence to any applicable mandatory
reporting requirements already set forth in New Jersey?s administrative code or other regulations.

q Referral made to the applicable accrediting agency Date:
q Referral made to APS Date:
q Referral made to State Division of Developmental Disabilities Date:
q Referral made to State Division of Health Facilities Evaluation and Licensing Date:
q Referral made to Law Enforcement; if so did member press charges? q YES q NO Date:
q Referral made to the OOIE Date:
q Other referral made to: Date:
Was the Critical Incident resolved at time of the report to Horizon NJ Health. If so, how:

If incident is unresolved at time of report, is the incident presently under investigation, and if so, by whom?

MLTSS Critical Incident Reporting Guide
Provider Services: 1-855-777-0123



MLTSS Critical Incident Reporting Guide
Provider Services: 1-855-777-0123

Types of Critical Incidents

Unexpected death of a member

Death of a member that was not medically anticipated. Examples
include suicide, homicide and/or unanticipated death due to
unforeseen circumstances/complications. Example: A healthy
member goes into the hospital for a routine procedure,
develops complications and succumbs to the complications
two weeks later.

Media involvement or the potential for media involvement

An event involving a member that has been or may be made
known to the public through any media, including but not limited
to newspaper, television, radio, websites, and social media.

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

A physical act directed at a member of a type that could tend to
cause pain, injury, and/or suffering. Such acts include but are not
limited to the member being kicked, pinched, bitten, punched,
slapped, hit, pushed, dragged, and/or struck with a thrown or
held object.

Psychological / Verbal abuse

Any verbal or non-verbal acts or omissions which inflict emotional
harm, mental distress, invocation of fear and/or humiliation,
intimidation, degradation, or demeaning a service member.
Examples include, but are not limited to: teasing, bullying,
ignoring need, favoritism, verbal assault, or use of racial slurs, or
intimidating gestures (i.e., shaking a fist at a member).

Sexual abuse and/or suspected sexual abuse

Any activity with a member for the purposes of sexual stimulation
of the actor or another person when the member does not
consent, or when the member is incapable of resisting, giving, or
declining consent to the sexual activity due to age, disability, or
fear of retribution or hardship.

Fall resulting in the need for medical treatment

A fall, defined as a sudden, uncontrolled, unintentional, non-
purposeful downward displacement of the body to the floor/
ground, or hitting another object, by a member resulting in need
for medical treatment for that member.

Medical emergency resulting in need for medical treatment

A medical condition manifesting itself by acute symptoms of
sufficient severity, (including severe pain) such that a prudent
layperson, who possesses an average knowledge of medicine
and health, could reasonably expect the absence of immediate
medical attention to result in placing the health of the member
(or, with respect to a pregnant woman, the health of the woman
or her unborn child) in serious jeopardy; serious impairment
to bodily functions; or serious dysfunction of any bodily
organ or part.

Medication error resulting in serious consequences

Any preventable event that may cause or lead to inappropriate
medication use or resident harm, while the medication is in
the control of the health care professional. Such events may
be related to professional practice, health care products,
procedures, and systems including: prescribing; order
communication; product labeling, packaging and nomenclature;
compounding; dispensing; distribution; administration;
education; monitoring; and use.

Psychiatric emergency resulting in need for medical treatment

A situation in which a member is doing serious harm to him/
herself or others, or in which the member?s health is significantly
impaired or where there is clear evidence that this will occur in
the immediate future. In such situations, action must be taken
immediately to prevent or minimize harm to the member
or others.

Severe injury resulting in the need for medical treatment

An accidental, self-inflicted, or intentional damage to the
member?s body by an external force resulting in the need for
medical treatment for the member.

Suicide attempt resulting in the need for medical attention

An act with a non-fatal outcome in which a member deliberately
initiates a behavior that, without intervention from others, will
cause self-harm, or deliberately ingests a substance in excess of
the prescribed or generally recognized therapeutic dosage that
will cause self-harm.

Neglect/Mistreatment, caregiver (paid or unpaid)

The failure of a caregiver (person responsible for the member?s
welfare whether paid or unpaid) to provide the needed services
and supports to ensure the health, safety, and welfare of the
member. These supports and services may or may not be defined
in the member?s plan or otherwise required by law or regulation.
This includes acts that are intentional, unintentional, or careless
regardless of the incidence of harm. Examples include, but are
not limited to, the failure to provide needed care such as shelter,
food, clothing, supervision, personal hygiene, medical care, and
protection from health and safety hazards.

Neglect/Mistreatment, self

An act or failure to act by a member which results in the
inadequate provision of care or services necessary to maintain
the physical and mental health of the member, and which places
the member in a situation which can result in serious injury
or which is life-threatening. This includes failure to provide
adequate food, clothing, shelter and health care for one?s own
needs. Types of Critical Incidents

(Continued)



Products are provided by Horizon NJ Health. Communications are issued by Horizon Blue Cross Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for
all its companies. Both are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross? and Blue Shield? names and symbols are registered marks of the Blue Cross
and Blue Shield Association. The Horizon? name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey. ? 2019 Horizon Blue Cross Blue Shield of New Jersey,
Three Penn Plaza East, Newark, New Jersey 07105. EC003089

horizonNJhealth.com

Types of Critical Incidents (continued)

MLTSS Critical Incident Reporting Guide
Provider Services: 1-855-777-0123

Neglect/Mistreatment, other

The member fails to receive the needed services and supports to
ensure the health, safety, and welfare of the member for reasons
not otherwise listed.

Exploitation, financial

Any willful, unjust, or improper use of a member?s cash, assets,
or funds for the benefit or advantage of another. This may occur
without the explicit knowledge or consent of the member. This
also may include identity theft.

Exploitation, theft

Any willful, unjust, or improper use of a member?s property
or possessions that are taken without knowledge, consent or
authorization for the benefit of another. This may include taking of
valuables, medications, or other personal property.

Exploitation, destruction of property

Any willful, unjust, or improper injury to member?s real or personal
property through another?s actions for the benefit or advantage of
another.

Exploitation, other

Any willful, unjust, or improper use of a member or his/her
property, for the benefit or advantage of another; condoning
and/or encouraging the exploitation of a member by another
person. An example of exploitation includes, but is not limited to,
requiring a member to perform functions/activities that are solely
for another?s convenience.

Theft with law enforcement involvement

A willful or unexplainable incident, perpetrated by any person,
resulting in member property or monetary funds being stolen or
missing with law enforcement involvement.

Failure of member?s Back-up Plan

The Back-up Plan agreed to in the Plan of Care fails to provide for
the needs of the member when the member, caregiver, provider,
or the Care Manager identifies a gap in care or when a caregiver
identifies an unsafe or threatening environment at the Member?s
residence.

Elopement/Wandering from home or facility

The act of a member who requires supervision for his/her health
or safety, leaving the grounds of a facility, Community Alternative
Residential Setting (CARS), or his/her home without authorization
and who cannot be located after a diligent and reasonable search.

Inaccessible for initial/on-site meeting

A member who cannot be contacted using contact information
available in the member?s record prior to the development of the
initial Plan of Care.

Unable to Contact

A member whose whereabouts are unknown, is absent, without
notification, and who cannot be contacted using the contact
information available in the member?s Care Management record.

Inappropriate or unprofessional conduct by a provider
involving member

Any conduct or practice contrary to recognized standards of
ethics of the provider that does or might constitute a danger
to the health, welfare or safety of the member or any conduct,
practice or condition that does or might impair the ability to
provide services safely and skillfully.

Cancellation of utilities

The cancellation or termination of a member?s public utilities, such
as electricity, natural gas, water, or sewer due to non-payment or
for any other reason.

Eviction/loss of home

The eviction or displacement of a member from their community
residence due to legal action or any external force.

Facility closure, with direct impact to member?s health
and welfare

The closing or relocation of a nursing facility or assisted living
residence, whether planned or as an emergency situation, that
results in a risk to the member?s health or safety. An ?emergency
situation? may include: the suspension or revocation of the
residential license; decertification of the facility; or any other
event as prescribed by regulation of the respective legal authority
(i.e. commissioner, fire marshal, zoning officer, etc.). ?Planned
situations? that result in a risk to the health or safety of a member
shall be reported.

Natural disaster, with direct impact to member?s health
and welfare

An act of nature of such magnitude as to create a catastrophic
situation in which the daily patterns of life are suddenly disrupted,
resulting in a potential or actual risk to the member?s life, safety, or
well-being.

Operational Breakdown

Any situation or event which may cause a threat to life or safety
and/or impact on facility operations. This may include utility
outage or loss of use of equipment; environmental incidents ?
spills/illegal dumping; fire; mass disturbances (i.e. riot); public
safety issue; unexpected staff shortage; or accidental or willful
destruction of property.

Other

Any other situation or event that negatively impacts a member
that is not reported in other categories resulting in a potential or
actual risk to the member?s life, safety, and well-being.