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Enhancement

By Akisia Agard

As EPIC’s new Quality Enhancement Manager, many people have asked me to explain my perspective
on this role. So, I invite you to explore the amazing world of what I consider Compassionate Quality En-
hancement implemented here at EPIC. We ensure that compliance is the foundation, incident reporting
and investigation are the pillars, and compassion for everyone involved is at the top of what I consider the
temple of quality.

Incident and Investigation is a Major aspect of Quality Enhancement that must be maintained for the
Agency to remain in compliance. Incidents can be reportable or internal in nature. However, not all inci-
dents require an investigation. When an incident occurs, the Developmental Disabilities Administration
(DDA) Policy on Reportable Incidents and Investigations (PORII) provides the guiding principles that stipu-
lates what should be reportable or internally investigated. Incidents must be submitted by the agency
(e.g., EPIC) electronically within a prescribed timeframe to the Office of Health Care Quality (OHCQ) and
the Developmental Disabilities Administration Regional Office, to remain in compliance.

Additionally, Incidents can be further broken down into Type 1 and 2. For example, Abuse, Neglect, Death,
Hospital Admission/Emergency Room Visits, Injury, Medication error and Choking are all Type 1 , while
Type 2 covers restraints, unexpected or risky absence, theft of an individual's property or funds, and law
enforcement/fire department/emergency medical services.

Reporting is time sensitive, for example, if an incident of Hospital Admission occurred on Feb 1, according
to (PORII), this is reportable. Therefore, an initial Agency Investigation Report (AIR), must be completed in
the provider Consumer Information System (PCIS2) within 24 hours of discovery. The complete or final AIR
must then be submitted by Feb 10, and an AIR Addendum must be completed by Feb 20 and presented to
the standing committee for review.

Conversely, if an incident needs to be internally Investigated a report must be completed within 24 hours
and uploaded to (PCIS2). All such incident reports are then submitted electronically to (OHCQ) and (DDA)

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