Form CMS-10692 HCBS Incident Management Survey

Incident Management System Survey – All Questions

Section I - Introduction
The purpose of this survey is to help the Centers for Medicare & Medicaid Services (CMS)
identify state best practices related to the incident management system for Home and
Community Based Services (HCBS) under the 1915(c) waiver including reporting incidents,
responding to reported incidents, collecting information, training individuals involved in
incident management, and tactics for preventing incidents. We recognize your system may
not match exactly with some questions asked. Please aim to use the response option
available as best as possible. In addition, you will find space at the end of each section to
explain your state’s differences. We ask that respondents are honest and give the best
possible answer.
PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are
required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0938-TBD (Expires: TBD). This information
collection is mandatory for states with 1915(c) Home and Community-Based Services waivers (42
U.S.C. 1396n(f)(1)). The Secretary shall monitor the implementation of waivers granted under this
section to assure that the requirements for such waivers are being met and shall, after notice and
opportunity for a hearing, terminate any such waiver determined to be noncompliant. Under the Privacy
Act of 1974, any personally identifying information obtained will be kept private to the extent of the law.
The time required to complete the information collection is estimated to average 60-90 minutes,
including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

General Identifiers
1. Please provide us with your name:
2. Please provide us with a phone number and an email:
a. Phone number
b. Email address
3. What is your position?
4. How long have you been acting in this position?
a. Less than 1 year
b. 1-3 years
c. 4-7 years
d. 8-10 years
e. 10+ years
5. What state do you represent?
a. Dropdown list of states
6. What type of agency do you represent in relation to the waivers for which you are
responding?
a. State Medicaid Agency (SMA)
b. Operating Agency
c. N/A

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Incident Management System Survey – All Questions
7. NOTE: This survey aims to understand the unique process and supports for incident
management by waiver. We recognize there may be different approaches by waiver.
If you are the person responsible for more than one waiver, please indicate if your
incident management operations are the same or unique across all waivers:
a. Same
b. Unique
c. Not sure/No information
7a. (If answer b is selected for #7) Since you selected that the incident management
operations are unique across waivers, please fill out a separate survey for each
waiver that has a different system.
a. (If answer a is selected for #7) If the same, what was the impetus for this
decision?
b. (If answer b is selected for #7) If unique, how are these differences
reconciled?
8. Please provide the program name(s) and waiver number(s) of the waiver program(s)
you administer that use the same incident management system. If you do not know
the waiver number, enter “no information.”
Program Name

Waiver Number

Response

Response

Program 1

•

•

Program 2

•

•

Program 3

•

•

Program 4

•

•

Program 5

•

•

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Incident Management System Survey – All Questions
9. What population does your waiver serve? (select all that apply)
Populations
Aged, Disabled,
or Both – General
– Aged,
Disabled/Physical,
Disabled/Other

Aged,
Disabled, or
Both –
Specific
Subgroups Brain Injury,
HIV/AIDS,
Medically
Fragile,
Technology
Dependent

Intellectual
Disability,
Developmental
Disability, or
Both – Autism,
Developmental
Disability,
Intellectual
Disability

Mental Illness –
Mental Illness,
Serious
Emotional
Disturbance

Waiver Program
#1 “entered text”
Waiver Program
#2 “entered text”
Waiver Program
#3 “entered text”
Waiver Program
#4 “entered text”
Waiver Program
#5 “entered text”
10. Which of your waivers support self-directed services? (select all that apply)
Yes

No

Waiver Program #1 “entered text”
Waiver Program #2 “entered text”
Waiver Program #3 “entered text”
Waiver Program #4 “entered text”
Waiver Program #5 “entered text”
11. Is the HCBS service provided in a managed care format?
a. Yes
b. No

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Incident Management System Survey – All Questions

Section II - System Questions
Purpose of this section:
Questions in this section are targeted towards understanding the processes or
technologies/systems you have implemented for your waiver programs to assist in
monitoring, tracking, and reporting incidents. We are interested in identifying the type of
system implemented (e.g., electronic vs. paper), staff responsibilities regarding system
maintenance and upkeep, costs and the interoperability of system. The purpose of the
questions in this section is to help us get a sense of how programs/states have implemented
their system technologies and processes to best track incidents that impact the health and
welfare of individuals. We recognize that states have differing definitions of “critical
incidents;” this survey will use the term “incidents” freely and will ask about how states
determine severity in questions following.

Incident Management System Technologies
1. Which entity operates/manages the system?
a. State Medicaid Agency
b. Operating Agency
c. Contracted party
d. Other (describe)
e. No information
2. How are initial reports of incidents filed? (select all that apply)
a. Electronically
b. Phone/hotline reports
c. Written forms (e.g., fax, PDF form, etc.)
d. Other (describe)
e. No information

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Incident Management System Survey – All Questions
3. (If answer a is selected for #2) Please describe the format/platform as best you can:
(select all that apply)
a. Email in-box system
b. Microsoft Word or PDF form
c. Excel-based tool on single user computer
d. Excel-based tool on shared system
e. Microsoft Access tool on single user computer
f. Microsoft Access tool on shared system
g. Web or cloud-based system with state only use
h. Web or cloud-based system with external user access and inter-agency use
i. Other (describe)
j. No information
4. (If answer a is selected for #2) What type of system is used?
a. State-operated system
b. Vendor-based system
c. Other (describe)
d. No information
5. (If answer b is selected for #4) Please provide the name of the vendor from whom
you purchased the system.
6. (If answer b is selected for #4) Does the vendor provide the state with technical
assistance support?
a. Yes
b. No
7. How much was the initial cost of your system?
a. $100,000 – $199,000
b. $200,000 – $299,000
c. $300,000 plus
d. No information
8. How much does it cost annually to maintain your system?
a. Less than $100,000
b. $100,000 – $199,000
c. $200,000 – $299,000
d. $300,000 plus
e. No information

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Incident Management System Survey – All Questions
9. Did you receive any federal match funding through the Advanced Planning Document
for this system?
a. Yes
b. No
c. N/A
10. Are you able to use your system to trend incidents over time?
a. Yes
b. No
c. N/A
11. Please fill out which modes you use for each of the different functionalities to the left:
Electronic

Manual

Phones/Hotline

Other

N/A

Records initial
incident
documentation
Triages incident
into critical
incident or other
incidents
Assigns
incidents to a
unit/division for
investigation and
follow-up
Trends incidents
Allows
interoperability
with other
systems
Other (describe)
12. Provide a list of all other system or data sources that are linked to the incident
management system:
If there are no other data sources linked, please enter "none."

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Incident Management System Survey – All Questions
13. Who has access to the system to directly report incidents? (select all that apply)
a. Case Manager
b. Caregiver
c. Provider Agency
d. State Medicaid Agency
e. Operating Agency
f.

State Program Integrity Staff

g. Contracted Entity Staff
h. Disability Rights Group
i.

Ombudsman

j.

Law Enforcement

k. Protective Agencies (e.g., APS/CPS)
l.

Managed Care Organization

m. Other (describe)
n. None of the Above
14. Who has access to the information in the incident management system? (select all
that apply)
a. Case Manager
b. Caregiver
c. Provider Agency
d. State Medicaid Agency Staff
e. Operating Agency
f.

State Program Integrity Staff

g. Contracted Entity Staff
h. Disability Rights Group
i.

Ombudsman

j.

Law Enforcement

k. Protective Agencies (e.g., APS/CPS)
l.

Managed Care Organization

m. Other (describe)
n. None of the Above

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Incident Management System Survey – All Questions

Incident Management System Processes
15. How does the state define the responsibilities of each staff/provider selected in the
previous question? (select all that apply)
Statement of
Protocol

Training

State
Regulations

State Law

Case Manager
Caregiver
Provider Agency
State Medicaid
Agency
Operating
Agency
State Program
Integrity Staff
Contracted
Entity Staff
Disability Rights
Group
Ombudsman
Law
Enforcement
Protective
Agencies (e.g.,
APS/CPS)
Managed Care
Organization
Other (describe)
None of the
above

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Incident Management System Survey – All Questions
16. Which individuals of the following have responsibility for the following activities?
(select all that apply) Please select who is responsible for each activity to the left.
View incident terms and conditions.
Case
Caregiver Provider State
Manager
Agency Medicaid
Agency
Staff

State
Contracted Other
Program 3rd Entity
(describe)
Integrity
Staff

Receive initial
incident report
Triage initial
incident report
Contact
individual/advocate
about report
Refer incident to
additional
investigative
authorities
Create summary
report
Follow-up with
individual
Collect data from
reported incidents

General
17. Please identify the strengths of the functionality of your incident management
system.
18. Please identify the weaknesses of the functionality of your incident management
system.
19. Has your state/agency faced any struggles, issues, or barriers with the functionality
of your incident management system? If so, please explain.
20. Please provide any clarifying information for any questions you had difficulty
answering because your system is different from what the survey is asking.

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Incident Management System Survey – All Questions

Section III - Reporting Questions
Purpose of this section:
In this section, we would like to understand how states receive and collect data on reported
incidents. We ask about who inputs and tracks incident information, what information is
collected, when incidents are required to be reported, and what monitoring activities the
state completes for reported incidents. Further, we are also hoping to identify if data
collected is trended and finally if there are any reporting differences for self-directed services
participants, as applicable.

Reporting Guidelines
1. Does the state identify incidents by risk level?
a. Yes
b. No
c. N/A
2. (If answer a is selected for #1) How does the state define an incident as a “critical”
incident? (select all that apply)
a. Abuse that results in Emergency Room (ER) Visit
b. Abuse that results in physical injury (non-ER visit)
c. Neglect that results in ER visit
d. Neglect that results in physical injury (non-ER visit)
e. Exploitation that results in ER visit
f.

Exploitation that results in physical injury (non-ER visit)

g. Accidental/Unexpected Death
h. Other (describe)
i.

No information

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Incident Management System Survey – All Questions
3. What information is required when reporting a non-critical incident and a critical
incident? (select all that apply)
If the same information is required for both non-critical and critical incidents, please
check in the "applies to both" column.
Non-Critical Incident

Critical Incident

Applies to Both

Level of incident
Identifying data
Location
In own-home or
provider-controlled
home setting
Estimated time of
incident
Date of incident
Provider information
Case Manager
information
Witnesses
Other (describe)
4. Are there standardized forms or database interfaces for reporting incidents to the
state?
a. Yes
b. No
c. N/A
5. Which of the following does the state use to require incident reporting? (select all that
apply)
a. State legislative law
b. State regulations
c. Contractual agreement with providers
d. Other (describe)
e. N/A

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Incident Management System Survey – All Questions

Reporting Timelines
6. Are staff trained to produce summary reports?
a. Yes
b. No
c. N/A
7. What is the timeliness standard for reporting incidents? (select one answer for each
column)
If the timeline is implemented for both non-critical and critical incidents, please check
in the "applies to both" column.
Non-Critical Incident

Critical Incident

Applies to Both

Immediately
24 hours after
incident is
found/recognized
Next business day
Within 2-5 business
days
No Information

Assessing Compliance with Reporting Requirements
8. How does the state monitor compliance and how often? (select all that apply)
Monthly

Quarterly

Every 6
months

Annually

Other

Compliance
review
Individual
survey
Automated
summary
from tracking
tool
Other
(describe)

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Incident Management System Survey – All Questions
9. Does the state allow the person to report ANE/critical incident anonymously?
a. Yes
b. No
c. N/A

Reporting Self-Direction Services
10. Does the state have a separate reporting system for participants with self-direction?
a. Yes
b. No
c. N/A
11. (If answer a is selected for #10) What data or information is required when reporting
a critical incident for individuals with self-directed services? (select all that apply)
a. Level of incident
b. Identifying data
c. Location
d. Estimated time of incident
e. Description of incident
f.

Date of incident

g. Provider information
h. Case Manager information
i.

Witnesses

j.

Other (describe)

k. N/A
12. (If answer a is selected for #10) What tools are used to report incidents for selfdirected services? (select all that apply)
a. Paper
b. Web-based entry
c. Phone/hotline
d. Fax
e. Other (describe)
f.

N/A

General
13. Please identify the strengths of the reporting procedures for your incident
management system.
14. Please identify the weaknesses of the reporting procedures for your incident
management system.

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Incident Management System Survey – All Questions
15. Has your state/agency faced any struggles, issues, or barriers with the reporting
procedures for your incident management system? If so, please explain.
16. Please provide any clarifying information for any questions you had difficulty
answering because your system is different from what the survey is asking.

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Incident Management System Survey – All Questions

Section IV - Incident Resolution Questions
Purpose of this section:
In this section, we are hoping to gain a better sense of how your state resolves incidents
once they are identified and reported. The answers to the questions in this section will help
us understand the processes and procedures states have implemented to adequately
respond to incidents and help highlight any additional safeguards created for individuals.

Incident Resolution Process
1. After initial incident reports, who is responsible for each of the following activities to
the left (select all that apply):
SMA
Staff

Operating
Agency
Staff

Provider
Agency
Staff

Quality
Assurance
Unit Staff

Program
Integrity
Staff

Contracted
3rd Party

Other

Responds
to the report
Investigates
the reported
incident
Closes the
report
Conducts
follow-up
2. How does the state determine whether a closed report needs follow-up?
3. Does the state monitor whether staff are trained in performing follow-up?
a. Yes
b. No
c. N/A

Investigation Process
4. Is an investigation performed on all incidents reported?
a. Yes
b. No
c. N/A

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Incident Management System Survey – All Questions
5. (If answer b is selected for #4) How does the state determine which incidents to
investigate?
6. How are investigations performed? (select all that apply)
a. Desk review
b. On-site review
c. Phone calls
d. Other (describe)
e. No information
7. What methods are used during the investigation? (select all that apply)
a. Conducting on-site document reviews
b. Analyzing claims data
c. Meeting with provider who reported the incident and individual (separately)
d. Meeting with individual’s family or related/legal guardian
e. Interviewing alleged perpetrator
f.

Interviewing witnesses

g. Other (describe)
h. No information
8. How soon after the initial incident report must an investigation be initiated? (select
one answer per column) If the timeline for initiating the investigation is the same for
both non-critical and critical incidents, record answer in the "applies to both" column.
Non-Critical
Incidents

Critical Incidents

Applies to Both

Immediately
Within 24 hours
1-3 business days
4-5 business days
1-2 weeks
Within the month
Other (describe)
N/A

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Incident Management System Survey – All Questions
9. Which of the following qualifications satisfy state requirements for those conducting
investigations? (select all that apply)
a. Medical (e.g., nurse, therapist)
b. Social work (e.g. social worker, clinical psychologist, case manager)
c. Law enforcement
d. Has fiscal experience (e.g. actuary)
e. Other (describe)
f.

N/A

Incident Resolution for ANE
10. If the incident involves the death of an individual, what are the protocols for review or
investigation?
11. Does the state conduct mortality/morbidity reviews?
a. Yes
b. No
c. N/A
12. What is the state’s burden of proof used to substantiate allegations?
a. Preponderance of evidence (over 50%)
b. Clear and convincing (greater than 51% and less than 75%)
c. Beyond a reasonable doubt (greater than 95%)
d. Other (describe)
e. No information
13. Does the state use allocated state Medicaid funds to finance remediation costs
related to incidents for ANE victims?
a. Yes
b. No
c. N/A
14. Does the state have a backup plan (i.e. backup provider) for providing alternative
providers to an individual when providers are under investigation for ANE?
a. Yes
b. No
c. N/A
15. Does the state respond differently to reports of ANE on self-direction individuals?
a. Yes
b. No
c. N/A

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Incident Management System Survey – All Questions
16. (If answer a is selected for #15) How does the state respond differently to reports of
ANE on self-direction individuals?
17. Are results from investigations or confirmed reports of ANE shared with the state
licensing department?
a. Yes
b. No
c. N/A
18. Do you communicate with neighboring states regarding providers found guilty of
ANE?
a. Yes
b. No
c. N/A
19. Are costs recouped if provider is found guilty of ANE?
a. Yes
b. No
c. N/A

Sharing Results After Incident Resolution
20. How are the results of the investigation communicated? (select all that apply)
a. Investigation results are sent to operating agency staff
b. Available on state intranet
c. Shared with program investigation staff
d. Shared with individual, guardian and/or family member
e. Other (describe)
f.

N/A

21. Are results shared with other branches of the state Medicaid agency (e.g. persons in
charge of staffing)?
a. Yes
b. No
c. N/A
22. Are results shared with provider agencies?
a. Yes
b. No
c. N/A

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Incident Management System Survey – All Questions
23. What safeguards does the state have for self-direction individuals? (select all that
apply)
a. Program/state helps individual find a new provider
b. Program/state allows anonymous reporting
c. Provides specialized training
d. Other (describe)
e. N/A

Conducting Audits on Reported Incidents
24. Who audits the investigation/incident resolution process? (select all that apply)
a. State Medicaid Agency
b. Operating Agency
c. State Program Integrity Unit
d. Contracted 3rd party
e. Other (describe)
f.

No information

25. How often are audits on investigation/incident resolution processes conducted?
(select all that apply)
a. Monthly
b. Quarterly
c. Annually
d. Every 2 years
e. Ongoing
f.

Prior to closure of investigation

g. Other (describe)
h. No information

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Incident Management System Survey – All Questions
26. What type of data is used to conduct the following? (select all that apply)
Investigation

Follow-up

Audit

Incident report
Claims
ER or
Medicaid/medical
claims other than ER
Medical/ER records
Self-reported data
Survey/interview
Desk audit
Onsite audit
Licensing report
Case managing
reports
No information
27. Have state audits resulted in identifying incidents that have not been reported but
should have been? (e.g., has the audit found ER utilization for falls or other incidents
where there was no documentation of an incident?)
a. Yes
b. No
c. N/A

General
28. Please identify the strengths of the incident resolution process of your incident
management system.
29. Please identify the weaknesses of the incident resolution process of your incident
management system.
30. Has your state/agency faced any struggles, issues, or barriers with the incident
resolution process of your incident management system? If so, please explain.
31. Please provide any clarifying information for any questions you had difficulty
answering because your system is different from what the survey is asking.

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Incident Management System Survey – All Questions

Section V - Quality Improvement Questions
Purpose of this section:
In this section, we will be seeking to understand if your state trends and tracks incidents and
whether the collected data regarding incidents helps to inform quality improvement
strategies to improve procedures, data collection processes, or training. We are also
interested in seeing how the state is using the information collected from incidents to
improve care and prevent further incidents.

Creation of Data Reports and Trends
1. Do you create trend reports (this is a report that aggregates data from multiple
incident reports to identify trends) for any of the following: (select all that apply)
a. Recurrent incidents (e.g., by individual and/or by provider)
b. Outliers
c. Number of incidents
d. Type of incidents (e.g., falls, ANE, other)
e. Results of substantiated ANE
f.

ER visit/hospitalizations

g. Particular medical findings (e.g., aspiration, pneumonia, falls, urinary tract
infection (UTI), burns)
h. Other (describe)
i.

N/A

2. If trends are analyzed, how are incidents aggregated and analyzed for a trend
report?
a. Manually
b. Electronically
c. Other (describe)
3. How often are reports produced? (select all that apply)
a. Monthly
b. Quarterly
c. Annually (e.g., 372 reports)
d. Every 2 years
e. Every 3 years (e.g., Evidentiary Reports)
f.

Ad hoc or as necessary

g. Other (describe)
4. If you have a link or a file of the most recent trend report, please share the
link/upload below:
File upload:

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Incident Management System Survey – All Questions
5. Please choose the top three trends you have discovered:
a. Recurrent incidents (e.g., by individual and/or by provider)
b. Results of substantiated ANE
c. ER visit/hospitalizations
d. Particular medical findings (e.g., aspiration, pneumonia, falls, UTI, burns)
e. Deaths (natural and unexpected)
f.

Other (describe)

g. N/A
6. Who is responsible for producing the trend report? (select all that apply)
a. Case Manager
b. Caregiver
c. Provider Agency
d. SMA Staff
e. Operating Agency Staff
f.

State Program Integrity Staff

g. Contracted Entity Staff
h. Other (describe)
i.

N/A

7. Does the state publish (release to the public) a report on all incidents?
a. Yes
b. No
c. No Information
8. (If answer a is selected for #7) How often are these reports issued? (select all that
apply)
a. Monthly
b. Quarterly
c. Annually (e.g., 372 reports)
d. Every 2 years
e. Every 3 years (e.g., Evidentiary Reports)
f.

Other (describe)

9. To whom are these reports issued? (select all that apply)
a. CMS
b. Operating Agency
c. State Medicaid Agency
d. General Public
e. Other (describe)

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Incident Management System Survey – All Questions

Use of Data and Trend Reports
10. Has your state implemented a systemic or operational intervention in response to any
trend report within the last five full waiver years?
a. Yes
b. No
c. No information
11. (If answer a is selected for #10) After implementation of the intervention, did the
number of incidents decrease?
a. Yes
b. No
c. No information
12. Has the state created new trainings based on findings from trend reports?
a. Yes
b. No
c. No information
13. Have you implemented performance metrics in response to findings in trend reports?
a. Yes
b. No
c. No information
14. (If answer a is selected for #13) What performance metrics have you added?
15. How often are performance metrics reviewed and revised? (select all that apply)
a. Monthly
b. Quarterly
c. Every 6 months
d. Annually
e. Ad hoc or as necessary
f.

Other (describe)

g. No Information
16. Have you developed multi-department or multi-agency solutions intended to reduce
the number of incidents?
a. Yes
b. No
c. No information
17. From the trend reports, do you see a higher prevalence of incidents among
individuals who are receiving their services in their own home?
a. Yes
b. No
c. No information

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General
18. Please identify the strengths of your quality improvement strategies for your incident
management system.
19. Please identify the weaknesses of your quality improvement strategies for your
incident management system.
20. Has your state/agency faced any struggles, issues, or barriers with quality
improvement strategies for your incident management system? If so, please explain.
21. Please provide any clarifying information for any questions you had difficulty
answering because your system is different from what the survey is asking.

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Incident Management System Survey – All Questions

Section VI - Collaboration Questions
Purpose of this section:
Questions in this section are aimed to better understand how your state communicates and
collaborates with other departments or units within the operating agency or other responsible
agencies. We are also interested in how your state communicates and works with providers
to collect information about incidents.

Collaboration with Other Agencies
1. Does your agency work with other departments or agencies to collect information
regarding incidents?
a. Yes
b. No
c. N/A
2. (If answer a is selected for #1) Which of the following agencies or departments?
(select all that apply)
a. State Health and Human Services
b. State Medicaid Agency
c. Aging Department
d. Disabilities Department
e. Aging and Disabled Department
f.

Mental Health Department

g. Law Enforcement
h. Public Advocate for Disability Rights
i.

Provider Licensing Agency

j.

Provider Certification Agency

k. Quality Improvement Division (internal to the State Medicaid Agency)
l.

Quality Improvement Division (outside of the State Medicaid Agency)

m. Other (describe)

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Incident Management System Survey – All Questions
3. Does the agency collecting incident information share that information with other
agencies in your state?
a. Yes
b. No
c. N/A
4. (If answer a is selected for #3) What type of information is shared?
a. Issue reports
b. Investigation findings
c. Both issue reports and investigation findings
d. Other (describe)
5. Is the agency collecting incident information required by law or regulation to share
this information with other agencies or departments?
a. Yes
b. No
c. N/A
6. Please select how often information is shared for the different modes of sharing
information:
Weekly

Monthly

Quarterly

Every 6
months

Annually

As
necessary

Never

Using
incident
management
system
Email
Reports
Meetings
Other
(describe)
7. If the investigation staff collaborate with other agencies, how do they communicate?
(select all that apply)
a. Combined and/or accessible Database
b. Email
c. Phone
d. Reports
e. Meetings
f.

Other (describe)

g. Investigation staff does not collaborate with other agencies
h. No information
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Incident Management System Survey – All Questions
8. (If answer a is selected for #1) Which agency/department holds the responsibility for
sending the information to the enforcement agency?
a. State Medicaid Agency
b. Operating Agency
c. State Program Integrity Unit
d. Contracted 3rd Party
e. Other (describe)
f.

N/A

9. If there are differences in findings between various investigative entities (e.g. state
investigator v. Ombudsman, state investigator v. law enforcement, etc.), does the
state have a policy/procedure for reconciling those findings?
10. Is there a combined report for all the information found from different investigative
entities?
a. Yes
b. No
c. N/A
11. Do you share information regarding incidents with providers?
a. Yes
b. No
c. N/A
12. (If answer a is selected for #11) Describe the method used to share information
regarding incidents with providers:

General
13. Please identify the strengths of your system’s communication with other agencies
and providers.
14. Please identify the weaknesses of your system’s communication with other agencies
and providers.
15. Has your state/agency faced any struggles, issues, or barriers in your system’s
communication with other agencies and providers? If so, please explain.
16. Please provide any clarifying information for any questions you had difficulty
answering because your system is different from what the survey is asking.

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Incident Management System Survey – All Questions

Section VII - Training Questions
Purpose of this section:
The purpose of this section is to understand how the state/waiver program trains its staff,
providers, waiver participants and family/unpaid caregivers on incident reporting. This
section will go into detail on how the training is administered, how often it is administered,
what is covered during the training, and who monitors for training compliance.

Training
1. When are new providers required to receive training on incident reporting?
a. Before rendering services
b. After rendering services
c. Only in cases where the provider is found to be out of compliance
d. Other (describe)
e. N/A
2. (If answer b is selected for #1) What is the amount of time that a provider may render
a service before completing the training?
3. Are trainings updated based on: (select all that apply)
a. Stakeholder feedback
b. Investigative findings
c. Systemic interventions
d. Regulatory changes (e.g., state law changes)
e. Other (describe)
f.

N/A

4. Please select the answer to each question pertaining to training for providers, state
staff, waiver participants and family or unpaid caregivers for questions 4a through f.
(select all that apply)
a. Does the state provide initial and/or ongoing training, including any informal
trainings such as public awareness campaigns or state/regional conferences?
Providers

State
Staff

Waiver
Family/Unpaid
Participants Caregivers

Investigative Individuals
Staff
with SelfDirected
Services

Applie
s to All

Initial
Ongoing
Other
(describe)
N/A

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Incident Management System Survey – All Questions
b. How often is training updated? (select all that apply)
Providers State Waiver
Family/Unpaid Investigative Individuals Applies
Staff Participants Caregivers
Staff
w/Selfto All
Directed
Services
Monthly
Quarterly
Annually
As requested
Other
(describe)
N/A
c. What are the topics covered in training: (select all that apply)
If your training topics are the same across all populations listed on the
columns, please use "applies to all".
Providers State Waiver
Family/Unpaid Investigative Individuals Applies
Staff Participants Caregivers
Staff
w/Selfto All
Directed
Services
Definitions of
incidents
Definitions of
ANE
Types of
incidents to
report
Reporting
deadlines
Responsibilities
Identification
of/recognition
of ANE
Process of
reporting
incidents
Tracking
incidents

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Incident Management System Survey – All Questions

Trending
incidents
How to use the
incident system
How to perform
an investigation
Safeguards for
individuals and
those who
report
Communicating
with other
agencies or law
enforcement
Other
(describe)
Training not
provided
d. How is training administered? (select all that apply)
Providers State Waiver
Family/Unpaid Investigative Individuals Applies
Staff Participants Caregivers
Staff
w/Selfto All
Directed
Services
Web-based live
training
In-person
training
Self-paced web
training
Other (describe)
N/A

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Incident Management System Survey – All Questions
e. How does the state keep track of all providers/staff/caregivers/participants
that have received training? (select all that apply)
Providers

State Waiver
Family/Unpaid Investigative Individuals
Staff Participants Caregivers
Staff
w/SelfDirected
Services

Web-based
system
Training
records/sign-in
sheets
Other
(describe)
N/A
f.

Are training materials readily available? If training materials are available,
where can they be found? (please provide a link or description of where
materials can be accessed)
Yes

No

Providers
State Staff
Waiver Participants
Family/Unpaid Caregivers
Investigative Staff
Individuals w/Self-Directed
Services
Applies to All

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Applies
to All

Incident Management System Survey – All Questions

Delivery and Monitoring of Trainings
5. Who is responsible for developing and delivering the training to each of these
population groups (on the left)? (select all that apply)
Who is
responsible?
SMA

Operating
Agency

State Integrity
Division/Agency

Contracted
3rd Party

N/A

Providers
Caregivers
State Staff
Waiver
Participants
Individuals
with SelfDirected
Services
6. Who monitors the training of providers, caregivers, staff, and waiver participants?
(select all that apply)
SMA

Operating
Agency

State Integrity
Contracted
Division/Agency 3rd Party

No
Information

Providers
Caregivers
State Staff
Waiver
Participants
Individuals
with SelfDirected
Services

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Incident Management System Survey – All Questions

Training for Investigative Staff
7. What strategies does the state implement to train and/or retain skilled investigative
staff? Insert "N/A" if this does not pertain to you.

General
8. Please identify the strengths of your system’s training and education efforts.
9. Please identify the weaknesses of your system’s training and education efforts.
10. Has your state/agency faced any struggles, issues, or barriers with your system’s
training and education efforts? If so, please explain.
11. Please provide any clarifying information for any questions you had difficulty
answering because your system is different from what the survey is asking.

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Incident Management System Survey – All Questions

Section VIII - Prevention Questions
Purpose of this section:
In this section, we are seeking to identify current practices your state has implemented to
prevent future incidents. We are also interested in how your state identifies incidents that
have not been reported.

Identification of all Reportable Incidents
1. Of all incidents that occur in your waiver(s), what percent do you think are reported in
the Incident Management System?
a. 0 – 20%
b. 21 – 40%
c. 41 – 60%
d. 61 – 80%
e. 81 – 100%
f.

No information

2. (If answer a/b/c is selected for #1) What is the basis for your response to Question 1?
a. Review of provider documents (e.g. group home records, day training
records, etc.)
b. Review of hospital records (e.g. medical records, ER visit diagnoses, etc.)
c. Review of service recipients billing (e.g. payments made to doctors, clinics,
hospitals, etc.)
d. Case management visit records
e. Other (describe)
f.

No information

3. What measure are you taking to improve the reporting of incidents?
a. Review of provider documents (e.g. group home records, day training
records, etc.)
b. Review of hospital records (e.g. medical records, ER visit diagnoses, etc.)
c. Review of service recipients billing (e.g. payments made to doctors, clinics,
hospitals, etc.)
d. Case management visit records
e. Other (describe)
f.

N/A

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Incident Management System Survey – All Questions
4. a) Which activities has your state conducted in identifying incidents that have not
been reported? (select all that apply)
a. Data analysis (e.g. ER admission/discharge alerts, ER claims, 1st responder
claims)
b. Discussions with other agencies/departments
c. Discussions with providers
d. Regular meetings/sessions between individual and case manager
e. Focus groups with other waiver participants
f.

Other (describe)

g. N/A
4. b) Which of these activities selected have you found effective in identifying incidents
that have not reported?
a.

Data analysis (e.g. ER admission/discharge alerts, ER claims, 1st responder
claims)

b.

Discussions with other agencies/departments

c.

Discussions with providers

d.

Regular meetings/sessions between individual and case manager

e.

Focus groups with other waiver participants

f.

Other (describe)

g.

N/A

5. Have you provided training to providers and case managers highlighting risk factors
that help identify potential occurrence of incidents?
a. Yes
b. No
c. N/A
6. Have you provided training to providers and case managers highlighting
signs/symptoms that indicate potential occurrence of incidents (e.g. radial fractures,
long sleeve shirts in the summer time, visits to multiple primary care providers, and/or
ERs)?
a. Yes
b. No
c. N/A

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Incident Management System Survey – All Questions
7. Please choose the top two locations where you see incidents are most prevalent.
a. Own home
b. Provider-controlled setting
c. Residential settings
d. Day program settings
e. Within community
f.

Family member home

g. Other (describe)
h. N/A

Implementation of Safeguards to Prevent Incidents
8. Do providers or case managers routinely assess the potential for incidents?
a. Yes
b. No
c. No information
9. (If answer a is selected for #8) If an individual is categorized as high risk for a critical
incident, what safeguards does the state implement to monitor and prevent these
incidents? (select all that apply)
a. Additional home visits by provider/case manager
b. Additional check-ins with the individual by provider/case manager (via phone,
email, etc.)
c. Additional training sessions
d. Alerts or any incident reported elevated for faster response
e. Other (describe)
f.

No information

10. Other than direct reporting of an incident, have you identified other methods to
identify potential instances of incidents?
a. Yes
b. No
c. N/A

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Incident Management System Survey – All Questions
11. Have you implemented policies and processes to assist in identifying unreported
incidents?
a. Yes
b. No
c. N/A
12. Do you conduct additional analysis upon the occurrence of the following incidents?
Additional Analysis
Yes

No

Increase in provider visits
Missed appointments
Missed phone calls
Visit to the ER
Increase in prescription drug
use
Other (describe)
13. Do you increase the frequency of visits to the home if you identify additional risk
factors?
a. Yes
b. No
c. N/A
14. Does the state revisit or address unresolved reports or incidents?
a. Yes
b. No
c. N/A

General
15. Please identify the strengths of your system’s prevention efforts.
16. Please identify the weaknesses of your system’s prevention efforts.
17. Has your state/agency faced any struggles, issues, or barriers with your system’s
prevention efforts? If so, please explain.
18. Please provide any clarifying information for any questions you had difficulty
answering because your system is different from what the survey is asking.

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Incident Management System Survey – All Questions

Section IX - Mitigation of Fraud, Waste and Abuse Questions
Purpose of this section:
In this section, we are hoping to understand how your state uses its incident management
system to mitigate and prevent fraud, waste, and abuse (FWA). We will also be asking about
how your incident management system will communicate with other data systems in your
state and what safeguards are available for victims of FWA and/or ANE.
Any answers provided in this section are solely used for academic reasons and will not be
held against you. No information provided in this section can be used against you.
Therefore, please answer as truthfully as possible.
1. How often does the state verify incidents with claims to identify any FWA regarding
those providers? (select all that apply)
a. Monthly
b. Quarterly
c. Annually
d. Ad hoc or as necessary
e. Other (describe)
f.

N/A

2. When performing post payment reviews, are there any triggers or cross checks with
ANE reports and FWA?
a. Yes
b. No
c. N/A
3. How do you recuperate the payments provided to the provider found guilty of ANE?
4. Is there a cross check between ER admission data and HCBS data? (i.e. when
participants are in the ER, caregivers/providers know why they are there, alerts to
caregivers)
a. Yes
b. No
c. N/A
5. Are FWA provider lists integrated with ANE providers?
a. Yes
b. No
c. N/A
6. Are waiver participants notified of FWA providers?
a. Yes
b. No
c. N/A

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Incident Management System Survey – All Questions
7. Are waiver participants notified of ANE providers?
a. Yes
b. No
c. N/A
8. Is there additional training when cases of ANE/FWA arise? (i.e. when the state
deems necessary)
a. Yes
b. No
c. N/A
9. What topics are covered in the additional training?

General
10. Please identify the strengths of your system’s efforts to reduce FWA.
11. Please identify the weaknesses of your system’s efforts to reduce FWA.
12. Has your state/agency faced any struggles, issues, or barriers with your system’s
efforts to reduce FWA? If so, please explain.
13. Please provide any clarifying information for any questions you had difficulty
answering because your system is different from what the survey is asking.

Section X - Closing Comments
What can CMS do further to help you improve your incident management system? (If no
comments please enter N/A)
(If answer b is selected for #7 in Introduction) Since you selected that the incident
management operations are unique across waivers, please fill out a separate survey for
each waiver that has a different system.
Thank you for participating in this survey. The information you provided will be essential in
helping CMS understand the current landscape, develop future trainings to improve incident
management systems, and assist the states in responding to external audits.

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