Provider/External Delegates: Critical Incidents Reference Guide


A critical event is any actual or alleged incident/situation that creates a significant risk of substantial or serious harm to the physical or mental health, safety or well-being of an individual. Critical incidents are classified as abuse, neglect or exploitation.

If you or your staff witness, are told of, or suspect an incident of abuse, neglect or exploitation, it is important to report the allegation immediately.

Definitions

Abuse

The act of causing any physical, mental or sexual injury to a NextLevel Health Member adult or child, including manipulation (misuse) of a NextLevel Health Member financial resources.

Examples include:

  • Physical abuse, including inappropriately using drugs or physical restraints
  • Sexual Abuse
  • Mental/Emotional mistreatment (e.g. bullying, isolation, harassment)

Neglect

The result of another individual’s failure to provide a NextLevel Health Member adult or child the necessities of life including, but not limited to, food, clothing, shelter or medical care.

Examples include:

  • Self-Neglect (Mistreatment of self) Abandonment

Exploitation

The use of an individual’s resources without consent by another person and is to the disadvantage of the individual and profit or advantage of the person.

Examples include:

  • Financial misuse of an individual’s funds

Additional Examples of Critical Incidents

  • Sexual or physical assault
  • Serious injury, such as a burn, cut or puncture wound, bruising, falls
  • Denial of medication, food or other physical assistance
  • Neglect by a care giver
  • Physical isolation or confinement
  • Behavioral incidents
  • Verbal threats
  • Property damage
  • Criminal activity
  • Vehicle accident
  • Physical altercation

Guidelines for Reporting

Critical incidents should be reported within four hours of the initial discovery to the appropriate agency
(see below for agency listing), as well as NextLevel Health.

The reporter shall report allegations of physical, sexual or mental abuse; neglect by an employee, agency or facility; financial exploitation by an employee, agency or facility; injury or death of an individual that occurs in a facility or community agency.

Please note:  It is not a violation of HIPAA to give information in the case of abuse or neglect.

Required information includes:

  • Victim’s full name, date of birth, and medicaid identification number
  • Detail about the incident: what happened, when, where, how and identification of all witnesses
  • Information about the accused (if known) including the name, contact information and if the accused is currently working with or will be working with the alleged victim
  • Information about the person initiating the report (name, contact information, relationship to the victim and whether there is a need for anonymity)

Reporting Critical Incidents

Critical incidents can be reported to the following agencies:

NextLevel Health

Report your incident by:

Nursing Home Hotline

To report abuse, neglect or exploitation for those in hospitals or nursing homes call the Illinois Department of Public Health’s (IDPH) Ombudsman’s Hotline – 800-252-4343

Illinois Department of Aging (IDoA)

To report abuse, neglect or exploitation for elders not residing in a nursing home call the Elder Abuse 24-Hour Hotline – 866-800-1409 or 888-206-1327 (TTY)

Adult Protective Services Hotline

To report allegations of abuse, neglect or exploitation of individuals 18 to 59 years of age with a disability or people 60 years of age and older, call the Adult Protective Services Hotline – 866-800-1409  or
888-206-1327 (TTY)

Supportive Living Facility (SLF) Complaint Hotline

To report abuse, neglect or exploitation of Members in Supportive Living Facilities (SLF) – 800-226-0768

Department of Children and Family Services (DCFS) 

To report abuse, neglect or exploitation of a child– 800-252-ABUSE (800-252- 2873)