Provider's Serious Incident Review Committee

Note: Providers of AT, E-mods, Congregate and Home Delivered Meals and Home Visits by Medical Personnel will not be assigned the responsibility of investigating any allegations of a SRI unless they provide other services for which they are responsible for investigating incidents.

1. Organization and Membership of the Serious Incident Review Committee

  • The Committee may be organized on an agency-wide, multi-program or program-specific basis.
  • The Committee must contain at least five individuals. Participation of a cross section of staff, including professional staff, direct care staff and at least one member of the administrative staff is strongly recommended.
  • The Executive Director of the agency shall not serve as a member of the Committee but may be consulted by the Committee in its deliberations.
  • The Program Administrator for NHTD Waiver services may be designated as a member only if the Committee is an agency-wide or multi-program committee.
  • The individual assigned to conduct investigations for the agency can be part of the Committee, but may not serve on the Committee at the same time he/she is involved in an active investigation for the agency.
  • The Committee must meet at least quarterly, and always within one (1) month of a report of a SRI involving a NHTD waiver participant.

2. Responsibilities of the Serious Incident Review Committee

This Committee is responsible for reviewing the investigation of every SRI. The SIRC will evaluate whether the investigation has been thorough and objective. It will determine if the conclusions and recommendations of the investigator are in line with generally accepted professional standards and are in compliance with the guidelines of the NHTD waiver.

In addition, the Committee will:

  1. Assure that the providers' Incident Reporting Policies and Procedures comply with DOH NHTD Incident Reporting Policy as detailed in this Program Manual.
  2. Review all SRI and Recordable Incidents to assure that incidents are appropriately reported, investigated and documented.
  3. Ascertain that necessary and appropriate corrective, preventive, and/or disciplinary action has been taken in accordance with the Committee's recommendations. If other actions are taken, the Committee must document the original recommendations and explain why these recommendations were revised.
  4. Develop recommendations, if warranted for changes in provider policy and procedure to prevent or minimize the occurrence of similar situations. These recommendations must be presented to the appropriate administrative staff.
  5. Identify trends in SRI (by type, client, site, employee, involvement, time, date, circumstance, etc.), and recommend appropriate corrective and preventive policies and procedures to the agency administration.
  6. Report annually to QMS regarding SRI, Recordable Incidents and all corrective, preventive and/or disciplinary actions taken pertaining to identified trends. This report must include the name and position of each of the members of the committee and documentation of any changes in the membership during the reporting period). This report will be submitted to the QMS in each agency's region where the provider is authorized to provide waiver services by January 31 of each year for the prior year. A copy is also provided to the appropriate RRDS by the agency for further review, regional trend analysis and recommendations for interventions. QMS forwards the report with analysis to DOH WMS for further review. DOH may request reports at any time.

3. Documentation of Serious Incident Review Committee Activity

  • The chairperson shall ensure that minutes are kept for all meetings and maintained in one location.
  • Minutes are to be maintained in a manner that ensures confidentiality.
  • Minutes addressing the review of SRI shall state the identification number of the incident (provided by QMS and the participant's CIN, a brief summary of the situation that caused the report to be generated (including date and type of incident), Committee findings and recommendations, and actions taken on the part of the agency/program as a result of such recommendations.
  • DOH may request to review minutes at any time.

    All information regarding SRI reports, including but not limited to the information collected to complete the investigation and the investigation report and minutes of the standing SIRC, must be maintained separately from the participant's records.