Significant Incident Reporting

The following instructions are derived from CBH Provider Bulletin 20-20:

DBHIDS has revised the process for reporting Significant Incidents to supersede Provider Bulletin 18-13, which was released on August 1, 2018. This updated policy will take effect on November 16, 2020.

Definition of a Significant Incident

Any occurrence of a non-routine event, which is inconsistent with standards or practice and has or has the potential to jeopardize the health and/or wellbeing of an individual receiving service.

Reportable Significant Incidents include, but are not limited to, the following:

1. Death of a member
2. Restraints (physical, mechanical, and chemical)
3. Seclusion
4. Homicide committed by a member who is receiving services or has been discharged within 90 days
5. Suicide attempt (with or without medical intervention)
6. Act of violence requiring medical intervention (includes intervention provided by staff nurse/physician), by or to a member
7. Alleged or suspected abuse (physical, sexual, verbal, financial) of or by a member
8. Adverse reaction to medication and/or medication error administered by a provider (includes Medication Assisted Treatment dispensing errors)
9. Any physical ailment or injury that requires non-routine medical attention at a hospital on an emergency, outpatient, or inpatient basis (this includes visits to urgent care)
10. Neglect that results in injury or hospital treatment (committed by Mental Health Provider)
11. Elopement from facility:
    • Adults: A member who is out of contact with staff without prior arrangement or who may be considered to be in “immediate jeopardy” based on his/her personal history; any time the police are contacted about a missing person or the police independently find and return the member regardless of the time he or she was missing.
    • Children/Adolescents: A member who is absent from the facility premises without the approval of staff; any time the police are contacted about a missing person.
12. Missing person: a child who has not returned to home or facility within four hours, or an at-risk adult who has not returned home or facility within 24 hours (includes filing of a police report)
13. Police involvement or arrest (excludes involuntary commitments [302s])
14. Fire, flood, or serious property damage at a site where behavioral health services are delivered or a facility where members reside
15. Infectious disease outbreak at a provider site
16. All non-routine discharges from inpatient, residential rehabilitation (Drug & Alcohol), children’s residential treatment, detoxification, or methadone maintenance treatment (i.e., administrative/ involuntary discharges or leaving a facility against medical or facility advice [AMA, AFA])
17. Any sexual contact involving a minor, non-coerced or otherwise, that occurs at a provider site
18. Presence of contraband (illicit substances and synthetic cannabinoids) at a bed-based facility

Reporting Process

1. A copy of all reportable incidents must be faxed to the Quality Management Department at 215-413-7132 on the attached Significant Incident Report Form within 24 hours of an incidents’ occurrence or upon notification of an incidents’ occurrence. All Significant Incident Report Forms must indicate the Provider Number in Section 7 if applicable.
   • Significant Incident Reporting Form (PDF)
   • Significant Incident Reporting Form (Word DOC)
   • Reports of children who have not returned home or to the facility within four hours must be reported immediately.
   • Exception: All Long-Term Structured Facilities (LTSR) and Community Residential Rehabilitation programs (CRR) will only enter the reportable incident into the Enterprise Incident Management (EIM) system within 24 hours of the occurrence.
2. Any death which occurs at a provider facility must be immediately reported to the CBH’s Psychiatric Emergency Services (PES) line. The PES line can be contacted at 215-413-7171.
3. When an internal investigation is warranted, the provider must submit a copy of the investigative report to CBH within 14 days of the incident. Investigative reports must clearly document how the incident was investigated and the findings of the investigation, including any corrective actions taken to prevent further occurrence. Investigative reports may be faxed to the Quality Management Department at 215-413-7132 or mailed to:
   • Community Behavioral Health
     Quality Management Department
     801 Market Street, 7th Floor
     Philadelphia PA 19017
     Note: If an investigation is not completed within the designated 14 days, the provider must notify the Quality Management Department of the investigation status, including preliminary findings, and a projected investigation completion date.
4. Incidents involving alleged physical abuse, sexual abuse, and/or neglect of children must be reported to the Pennsylvania Department of Human Services (PA DHS). Providers are mandated by the PA DHS to report incidents directly by calling the Commonwealth’s Childline at (800) 932-0313 or submitting the information via the online portal.
5. Providers must submit the PA DHS notification letter (indicated/unfounded) to the Quality Management Department upon receipt. If the provider has not received a notification letter but has received a verbal communication from the PA DHS, the provider must notify the Quality Management Department of the date the verbal determination was provided and the name of the investigator providing the verbal determination. If an allegation is deemed indicated or a Licensing/Approval/Registration Inspection Summary Violation is issued the provider must submit a copy of the Licensing/Approval/Registration Inspection Summary Violation and the corresponding Corrective Action Plan submitted to the PA DHS.
6. Incidents involving alleged physical abuse, sexual abuse, and/or neglect of an adult between 18 and 59 years old, who has a physical or mental impairment that substantially limits one or more major life activities, must be reported to the PA DHS. Providers are mandated by the PA DHS to report incidents directly by calling the Commonwealth’s Protective Services Hotline at 1-800-490-8505.
7. A missing person who may be at risk should be reported to the Philadelphia Crisis Line by calling 215-685-6440, and a police report should be filed. The Philadelphia Crisis Line will notify the Crisis Response Center (CRC) so that they can notify the provider if the member presents at a CRC. In addition, a missing persons form should be completed here.

Where to Send Significant Incident Reports

• All reportable incidents must be faxed to CBH Quality Management at
  215-413-7132.
• Investigative reports may be faxed or mailed to CBH Quality Management:
  • Fax: 215-413-7132
  • Mail:
    Community Behavioral Health
    Quality Management Department
    801 Market Street, 7th Floor
    Philadelphia PA 19017
• Incidents involving the suspected abuse/neglect of children must be reported to the Commonwealth’s Childline:
  • Phone: 1-800-932-0313
  • Web: compass.state.pa.us/cwis/public/home
• An at-risk missing person should be reported to the Acute Services Mental Health Delegates at 215-685-6440.
• The death of a member at a provider facility must be reported to the CBH PES Line at 215-413-7171.
• Incidents involving the suspected abuse/neglect of an adult between 18 and 59 years old, who has a physical or mental impairment that substantially limits one or more major life activities, must be reported to the Commonwealth’s Protective Services Hotline at 1-800-490-8505.