Quality of Care
A Quality Incident can be detrimental to a member’s health or safety and may reflect that the care provided was below the professional standards of care. A concern about the quality of health care provided, or the appropriateness of the medical treatment received. A possible quality of care incident can involve a facility, the staff, a physician, or another entity providing a health care services to the member.
The goal of The Quality Department Investigations is to identify adverse outcomes whether at the provider level or a systemic issue; develop and implement plan of correction to reduce likely hood of reoccurrence or similar outcome, improving the care our members receive.
Medicare and Ambetter
Follow the instructions on the Potential Quality Issue (PQI) Referral Form (PDF) to submit Quality of Care concerns to the Medicare or Ambetter department.
Medicaid
The Arizona Health Care Cost Containment System (AHCCCS) Quality Management System (QMS) Portal is used for the submission of Incident/Accident/Death (IAD) reports for Behavioral Health providers only. IADs must be submitted by the provider within 2 business days of the incident. Please see the provider manual section on IAD reporting for further information.
For non-Behavioral Health providers, potential quality of care incident reports should be submitted to the Quality of Care mailbox within the timeframes indicated above. Submit all potential quality issues using the Arizona Complete Health Quality of Care Notification Form (PDF) to the following: AzCHQOC@AZCompleteHealth.com.
The following incident types are required to be reported by the provider:
- Deaths;
- Medication error(s);
- Abuse or neglect allegation made about staff member(s);
- Suicide attempt;
- Self-inflicted injury;
- Injury requiring emergency treatment;
- Physical injury that occurs as the result of personal, chemical or mechanical restraint;
- Unauthorized absence from a licensed behavioral health facility, group home or HCTC of children or recipients under court order for treatment;
- Suspected or alleged criminal activity;
- Discovery that a client, staff member, or employee has a communicable disease as listed in R9-6-202 (A) or (B);
- Incidents or allegations of violations of the rights as described in A.A.C. R9-20-203 or in A.A.C. R9-21, Article 2;
- Discrimination;
- Exploitation;
- Coercion;
- Manipulation;
- Retaliation for submitting grievances to authorities;
- Threat of discharge/transfer for punishment;
- Treatment involving denial of food;
- Treatment involving denial of opportunity to sleep;
- Treatment involving denial of opportunity to use toilet;
- Use of restraint or seclusion as retaliation; and/or
- Health Care-Acquired and Provider Preventable Conditions as described in the AHCCCS AMPM Chapter 900.
Providers must submit incident, accident, or death reports involving “sentinel events” within 6 hours of the occurrence. A “sentinel event” is defined as any of the following:
- Suicide or significant suicide attempt by a Member;
- Homicide committed by a Member;
- Unauthorized absence of a Member from a locked behavioral health inpatient facility;
- Sexual assault while a Member is a resident of a locked behavioral health inpatient facility; or
- Death while a Member is a resident of a Behavioral Health Inpatient Facility or other psychiatric hospital or other inpatient institution.
If you have any issues with the QMS Portal or need technical assistance, please contact the Quality of Care Team at AzCHQOC@AZCompleteHealth.com