Risk Management Incident Management
Contractual Compliance Activities Consumer Satisfaction Measures
Licensing and Certification Other Quality Indicators
The Division of Quality Assurance was established in January of 2001 in order to bring together and coordinate the many quality assurance initiatives that have been an on-going tradition at DDSN.
South Carolina State law requires licensing of day programs and residential facilities.The law authorizes the establishment of standards for the qualification of staff, staff ratios, fire safety, medication management, facility size and construction, storage of hazardous liquids and health maintenance. Licensing activities occur on a regular basis and may involve staff from DDSN, DHEC, and/or the State Fire Marshall’s Office.
For a description of the conceptual framework for DDSN's Quality Assurance Program, click here.
For a description of the Personal Outcome Measures utilized by DDSN, click here.
For information on the methods used towards Incident Management, click here.
Risk management and quality assurance are two sides to the same coin. Risk management activities strive to eliminate the potential negatives from a consumer’s life, while quality assurance activities strive to accentuate the positives. DDSN conducts many on-going risk management activities that assist in assuring that risks encountered in everyday life are kept as low as possible, as balanced against a consumer’s rights and desires for choice and autonomy.
- For a description of the conceptual framework for DDSN's Risk Management programs, click here.
- For a description of the initial structure of DDSN's Risk Management program, click here.
- For a description of how to determine any possible trends in Risk Management, click here.
- For guidelines on how to balance consumer risks with respect to Risk Management, click here.
SCDDSN Quality Management
DDSN recognizes that providers are the vital link in the continuing flow of information regarding Critical Incidents and Abuse, Neglect and Exploitation reporting. As part of our ongoing assessment and review process, we want to make the reporting process as complete, accurate, and efficient as possible. With that in mind, we offer some “REMINDERS” to assist in several important areas.
SOME IMPORTANT REMINDERS:
- Serious consumer injuries of unknown or unexplainable origin must be reported to the appropriate state investigative agency according to the procedures outlined in 534-02-DD. A serious injury of known cause (e.g., auto accident or fall) must be reported as a critical incident unless abuse is alleged in which case the report must be made to the appropriate state agency.
- Failure to provide proper supervision may be a form of neglect if the employee fails to intervene in a situation or provide proper supervision when they clearly have a duty to do so.
- Providers are required to have a safety plan in place whenever there is an allegation of abuse, neglect or exploitation. Please remember: 534-02-DD states the alleged perpetrator must be placed on administrative leave without pay pending the outcome of the investigation.
- If you have reported an incident to SLED and SLED did not investigate or vet to Local Law Enforcement (e.g., they vetted to the Ombudsman’s Office), and your own internal review indicates no violation of policy, you may return staff to active employment. You DO NOT need to submit a Request for Reinstatement of the employee(s). If your internal review indicates a violation of policy, follow your respective Agency and Personnel policies regarding issues of policy/procedure violations and disciplinary action. Once completed, you may return the employee to active employment.
- Only SLED, Local Law Enforcement or the Attorney General’s Office can make a determination of “founded” or “unfounded” on ANE Reports and Incidents. The Exception would be if a case was initially referred only to DSS, as in cases of Day Program reporting, then DSS CAN determine whether the allegation is founded or unfounded. The Ombudsman’s Office CANNOT make a determination of founded or unfounded criminal level abuse, neglect or exploitation. They may make a determination of non-criminal abuse, but this will not be counted as abuse according to the Omnibus Adult Protection Act.
- Submission of Addendum forms for Critical and ANE reports should reflect additional information subsequent to the Final Reports, verification of dates employees were reinstated and any change in disposition of administration/management review due to results of SLED or Local Law Enforcement investigations.
- If SLED accepts a report “For Information Only”, the ANE reporting process must be followed and Initial and Final ANE reports must be submitted to DDSN. Once SLED assigns an Intake Number, DDSN must follow this case to conclusion through required ANE reporting. If SLED vets a case of alleged ANE to the Ombudsman’s Office, you must still complete the required ANE reports and send to us, including the management review.
- Consistent with Directives 100-09-DD and 534-02-DD, reports must be submitted on the Incident Management System.
- For additional training information related to the DDSN Directives on Critical Incident and Abuse/ Neglect/ Exploitation reporting, the following slides are available:
- For technical assistance with the Incident Management System, please contact the DDSN Helpdesk at 803-898-9697.
Abuse, Neglect and Critical Incident Reporting - Frequently Asked Questions
- If SLED elects not to investigate a case (ICF/ID, non-ICF/ID and/ or day programs) and accepts the report “For information only”, does the provider have to conduct a review? Yes. SLED assigns an intake number for “Information only” cases and the information is entered into their database. As a result, we must have administrative closure to the case, and ANE reporting process must be followed. We need to know what prompted the call to SLED and what actions, if any, may have resulted. SLED will send DDSN a Case Status Report.
- If an allegation occurs at home or in the community, do we report to DDSN? If the person is served in an ICF/ID and is on a home visit, you must report to SLED and to DDSN. If the person is served in a non-ICF/ID setting, a licensed DDSN residence, or in a day program, the report must be made to DSS and documented in your agency files.
- When is a case considered “Closed?” If SLED investigates for criminal intent, the case is “Closed” when SLED sends their Case Status Report to DDSN. Cases vetted to the Ombudsman and DSS are “Closed” when the respective agencies render a finding. Employees are permitted to go back to work prior to case closure under certain circumstances as outlined in 534-02-DD.
- If an allegation is made in the community and staff is involved but not on duty, should staff be placed on leave? The staff must be placed on administrative leave without pay to protect the consumer from harm. The appropriate review must be completed.
- If a local law enforcement case is not founded, is the staff person allowed to return to work? DDSN must have written verification of case status from the LLE or SLED. The reinstatement request may be submitted with a valid justification only after a Management Review has been completed by the provider agency. If the reinstatement request is approved by DDSN, an Addendum to your report must be submitted within 24 hours.
- If abuse is alleged in a CRCF, is this reported in the same manner as an allegation in an ICF/ID is reported? No. The process for reporting an allegation in a DDSN operated CRCF is the same as a CTH or SLP.
- Which review process should be completed for an allegation in an ICF/ID? An Administrative Review of Alleged Abuse, Neglect, or Exploitation--ICF/ID Facilities should be completed.
- How are dates calculated for submission of Initial Critical/ANE and Final Critical/ANE Reports? The counting STARTS on the day the incident occurred or day of “discovery”/date incident was first reported. All Initial Reports must be submitted via IMS to DDSN Quality Assurance within 24 hours of the occurrence/discovery excluding week-ends and holidays. DDSN observes all State and Federal Holidays. However, Facility or Board observed holidays may also be included in calculating Final report due dates. Any observed holiday by your Facility or Board during the respective reporting period must be noted on reports to avoid incorrect calculations.
All Final Critical and Final ANE Reports must be submitted via IMS to DDSN Quality Assurance within 10 business days of incident date or date the incident was first reported/ discovered. However, Final Critical and ANE reports for incidents occurring in an ICF/ID must be submitted via fax within 5 days, excluding week-ends and holidays.
If the information or investigation is not concluded by the Final Report due date, submit the Final Report by the due date and then submit an Addendum when the investigation is complete or as new information becomes available.
Contract Compliance Activities
DDSN also conducts Contract Compliance Review (CCR) activities that provide a more in-depth look at the overall functioning of the provider agency. As part of this process, records are reviewed, consumers, staff, and family members interviewed, and observations made to assure that services are being implemented as planned, that the consumer/family still want and need them, and that they comply with contract and/or funding requirements and best practices.
Contract Compliance Review (CCR) Process
SC DDSN contracts with a Quality Improvement Organization, Alliant ASO, to conduct annual assessments of service providers by making on-site visits in its Contract Compliance Review (CCR) process. During this process, records are reviewed, consumers, staff, and family members interviewed, and observations made to make sure that services are being implemented as planned and based on the consumer’s need, that the consumer/family still wants and needs them, and that they comply with contract and/or funding requirements and best practices. In addition, the service provider’s administrative capabilities are reviewed annually to ensure compliance with DDSN standards, contracts, policies, and procedures.
Contract Compliance Review (CCR) Instruments
As another cornerstone in the foundation of Quality Management, DDSN maintains a program of performing contract compliance reviews. DDSN conducts these annual assessments of service providers by making on-sight visits under its Contract Compliance Review (CCR) process. As part of this process, records are reviewed, consumers, staff, and family members interviewed, and observations made to assure that services are being implemented as planned, that the consumer/ family still wants and needs them, and that they comply with contractual and/ or funding requirements and best practices. In addition to health and safety, the CCR process assesses the provider's basic administrative strengths and weaknesses, and where necessary, may refer a provider agency to receive special technical assistance or to undergo a more extended financial and managerial audit. These activities are very important to assure a foundation of quality service delivery. In conducting Contract Compliance reviews, DDSN utilizes the following forms and documents.
Review Instruments: In conducting Contract Compliance reviews, DDSN utilizes the following forms and documents.
Residential Observation Tool
FY2012-13 Compliance Review Key Indicator Crosswalk
FY2012-13 Compliance Review Key Indicators
SCDDSN Quality Management
Licensing and Certification
State law requires licensing of certain programs and residential facilities. This licensing relates to the health and safety aspects of facilities and services. The law authorizes the establishment of standards for the qualifications of staff, staff ratios, fire safety, medication management, facility size and construction, storage of hazardous liquids and health maintenance. All Residential and Facility-Based Day programs must be licensed. Licensing activities occur on a regular basis and may involve staff from DDSN, DHEC, and/or the State Fire Marshall’s Office. DDSN has contracted with Alliant ASO to conduct licensing inspections. The Application to Operate will continue to be submitted to DDSN, but Alliant ASO will complete the inspection. Upon approval, DDSN will issue the license to the provider to operate the facility.
The primary focus of the Licensing/ Certification review is to assure basic health, safety and welfare standards. Key indicators measure the following:
- The facility’s environment promotes the consumers’ health and safety.
- The physical plant of each facility, to include fire marshal inspections, HVAC, Water Quality, and Health and Sanitation.
- There must be evidence of Fire Safety training and evacuation, Disaster Preparedness, First Aid supplies and other emergency items.
- Facilities must provide documentation of continuous, coordinated health care, appropriate medical follow-up, and assistance with medications (as indicated in each consumers Plan).
- Facilities must demonstrate understanding and application of all DDSN policies regarding Abuse/ Neglect and Exploitation and Critical Incidents. Any instances of suspected abuse, neglect and/or exploitation as well as concerns relating to health and safety has resulted in appropriate action in accordance with Agency policy.
The facility review process must include an on-site review. During the course of the on-site review if substandard or noncompliant performance is found, the provider will be expected to take immediate corrective action.
As part of SCDDSN’s continuing efforts to improve the quality of services to people with lifelong disabilities, follow-up visits are completed with provider organizations. The purpose of the follow-up is to determine whether the plans of correction submitted to Alliant ASO have been implemented for all programs and locations.
In order to utilize staff and resources more effectively during this economic time, part of the follow-up process will be an opportunity for providers to submit evidence that the citations have been corrected. Documentation that verifies corrections have been made can be submitted to Alliant ASO prior to an onsite visit. This information should not be a repeat submission of the plan of correction. If the submitted documentation verifies correction, then an onsite review of that standard would not be necessary. The submission of documentation to verify correction of citations is voluntary, but a lack of documentation may necessitate an on-site review.
A report identifying the status of all citations will be issued after the completion of the follow-up survey.
For a copy of the Respite Standards that were established by DDSN, click here.
For a copy of the Residential Licensing Standards, click here.
For a copy of the Residental Habilitation/Certification Standards that were established by DDSN, click here.
Other Quality Indicators
DDSN collects, analyzes and reports information on how well service providers are performing on various other quality indicators which give an indication of the health and safety of each person, dignity and respect, personal choice, participation in the community and attainment of goals. Some of the ways this information is gathered include: comprehensive provider self-assessments, service coordinator oversight, peer reviews, consumer/ family monitoring, local human rights committee work, staff turnover, circle of support contacts, and the quality of facilitated plans.