5000. HEALTH AND SAFETY

5100. ADMINISTRATIVE INCIDENT REPORTING (AIRS)

5110. Purpose

This policy establishes uniform requirements for reporting and managing serious and emergent incidents involving the Children's Administration (CA). These incidents are defined as Administrative Incidents and must be reported through the Administrative Incident Reporting System (AIRS). This reporting system has been established to provide early notice and factual information for incidents requiring the immediate attention of the administration. Information from these reports will be used to identify issues, patterns and trends, and to determine if action is needed to improve the health and well being of children, families, and staff members.

5120. Scope

This policy's operating procedure applies to:

1. Children and families receiving services from CA.
2. Licensed and unlicensed facilities and providers.
3. Employees, interns, and volunteers of the Department of Social & Health Services (DSHS) as they relate to services CA provides.
4. Allegations of Employee Misconduct

   Allegations of employee misconduct or criminal conduct are not documented in AIRS. If an allegation of misconduct or criminal conduct may potentially receive media or other high profile attention, notification through the chain of command is made as soon as possible by telephone up to the Office of the Assistant Secretary. Allegations of employee misconduct and/or criminal conduct are addressed by following DSHS Personnel Policy 545 and DSHS Administrative Policy No. 6.01. In addition to these policies, appointing authorities follow the Washington State Patrol (WSP) and DSHS Interagency Agreement and protocol for complying with Executive Order 96-01.

5130. Incidents Requiring an AIRS Report

1. Child Fatalities/Near Fatalities

Child fatalities and near-fatalities resulting from allegations of child abuse and/or neglect on an open case are reported to the Office of Risk Management by telephone or by completing the Case and Management Information System (CAMIS) referral form within one hour from the time CA received notification of the incident. Child fatalities of Native American children also are reported to their respective tribe.

1. Child fatalities must be reported in AIRS if:
1. There is an open case on the family prior to the fatality incident or any CA history on the family within 12 months of the fatality, including information-only referrals.
2. The fatality occurred in a CA or Division of Child Care and Early Learning (DCCEL) licensed, certified, or state operated facility.
2. A near-fatality is defined as an act that places the child in serious or critical condition (RCW 74.13.500). Child near-fatalities must be reported if:
1. The near-fatality is a result of alleged child abuse and/or neglect on an open case or on a case with CA history within 12 months; or
2. The near-fatality occurred in a CA or DCCEL licensed, certified, or state operated facilit
y.
3. Child fatalities and near-fatalities must have a new referral created in CAMIS when:
1. They meet the above criteria.
2. The fatality or near-fatality is reported as being the possible result of child abuse or neglect regardless of whether or not the family has had prior contact with CA.
3. A new referral is not required when a near-fatality later becomes a fatality due to the circumstances reported in the original referral. An update to AIRS and a note in the Service Episode Record (SER) will suffice.
4. The initial report of fatality or near-fatality is input into AIRS by the intake supervisor or Child Protective Services (CPS) program manager at the time of the report. Updates to the initial report are documented in AIRS by the local office assigned to the case or where the case was last opened if the referral is not accepted for services.
2. Client Related

For the purpose of completing an Administrative Incident Report, a child client is defined as a child (or youth up to age 21) in the care, custody, or supervision of CA (per RCW 26.10) or DSHS as it relates to services CA provides. An AIRS report must be made on the following client related incidents:

1. Serious Injury: Serious injury of a child client requiring professional medical treatment (beyond first aid treatment) alleged to be the result of (a) physical abuse, (b) unexplained injury or (c) an injury that is not consistent with caretaker(s) explanation. Note: If it is a life-threatening injury, report the incident as a near-fatality.
2. Allegation of Molestation or Rape: Allegations of molestation or rape by an adult caretaker of a child client who is in the care and supervision of the department, or incidents involving multiple victims or patterns of molestation or rape between child clients placed by the department. Identify if the incident involved two residents in a facility, siblings, the caretaker, or third party adult.
3. Suicide Attempt: Any suicide attempt that results in injuries requiring hospitalization of a child client.
4. Placement Exceptions: Child is placed in one of the following placements: a) an institution not designed for foster children, such as adult mental hospitals or detoxification programs where children and adults are co-mingled; b) a foster home without specialized training and support to provide for the safety of children in the home where children reside who are sexually aggressive, physically assaultive or who have demonstrated a pattern of assaultive behavior; c) at DSHS offices due to no placement resources being available or at detention facilities once legal holds are eliminated; d) apartments or motels, unless an appropriate licensed foster home or relative caregiver is not available and only with approval from the Regional Administrator (RA) and a determination that adequate supervision is provided for the child.
5. Other: Any other client-related critical incident that does not fall into one of the previously identified categories that is believed to require administrative notification and/or attention.
3. Incidents Involving a Facility or Foster Home (Provider Incident)
1. An allegation of licensed provider misconduct is reported in AIRS by supervisors or management personnel. These include but are not limited to:
1. Criminal activity that would disqualify a licensed provider from providing care to children (see WAC 388-06-0170 & 388-06-0180).
2. Allegation of sexual abuse/sexual exploitation.
3. A pattern of high-risk child abuse and/or neglect referrals.
2. When an administrative incident meets one of the reporting requirements mentioned above and occurred in or involved one of the residents or staff in a facility or foster home, the Facility-Foster Home Section in AIRS is completed. Definition of facilities and foster homes include:
1. Foster homes, facilities, private agencies licensed by the Division of Licensed Resources (DLR).
2. Licensed childcare facilities licensed by DCCEL or facilities that meet the criteria for child care licensing.
3. Other licensed, certified, or state-operated facilities.
4. A person or agency subject to licensing under RCW 74.15.
4. Staff Safety Incident or Potential Threat of Harm
   (For additional information on staff safety, see Operations Manual 8600).

Individuals reporting a staff safety incident are required to indicate in AIRS whether or not the incident resulted in serious injury that required professional medical treatment. The following staff safety incidents require an AIRS report:

1. Serious Threat of Harm: A staff person or contracted provider feels their safety was/is in jeopardy, or they were/are at risk of harm as a result of receiving a threat.
2. Illness Serious/Communicable: Exposure to any blood borne pathogens, tuberculosis (TB), or any other serious/communicable illness (constituting a risk to others on the job) that is classified by the Department of Health (DOH) as requiring further evaluation, testing, and community education.
3. Environmental Hazard: Exposure of a staff person to any environmental hazard while in the course of carrying out job duties that require medical consultation to ensure the health of that person (e.g. exposure to methamphetamine manufacturing materials, etc.).
4. Traffic Accident: A traffic accident that occurs while a staff person is in the process of carrying out his or her job duties, whether in a personal or state-owned vehicle.
5. Physical Assault by Client: Assault of a staff person by a child, parent, or individual identified as a client receiving services from the department. Immediately notify law enforcement and document the jurisdiction and police report case number in the "Community" section of AIRS.
6. Physical Assault by Other: Assault of a staff person by any other person (non-client) that occurs during the course of the staff person carrying out his or her job duties. Immediately notify law enforcement and document the jurisdiction and police report case number in the "Community" section of AIRS.
7. Other: Any other serious issue that threatens the safety of staff.
5. Theft/Vandalism/Property Damage

Report incidents of theft, vandalism, damage, or loss of state or private property in excess of $250.

6. High Profile

These are incidents that may generate significant interest by the media, the legislature and/or the Governor's Office. Incidents reported as high profile, including those marked high profile by intake, are reported in AIRS and must include an explanation regarding the reason it is considered high profile.

7. Other

AIRS reports are not limited to the incidents described above. If other types of critical incidents requiring the attention of the administration occur, consult with the CA Office of Risk Management.

5140. Administrative Incident Management and Reporting Procedures

1. Administrative incidents identified in Section III are entered into AIRS within 24 hours of receipt of the report. The initial report is to include information known to the department at the time of the report.
2. Intake supervisors and/or CPS program managers input the initial AIRS report on child fatality and near-fatality cases. CPS program managers update and close the AIRS reports on child fatality and near-fatality cases.
3. Unit supervisors input the initial AIRS report on worker, staff safety, client related, and property loss incidents. Other incidents are input by intake supervisors or unit supervisors as determined by the region.
4. The supervisor of the unit responsible for investigating the incident ensures an AIRS report was made, updated, and closed when the investigation is completed. If there is not an investigation, the intake supervisor or the supervisor of the unit reporting the incident makes an AIRS report, updates, and closes as appropriate.
5. When automated transmission using AIRS is not possible, report the incident by phone to the Office of Risk Management and report in AIRS as soon as transmission is possible.
6. Managers in the chain of command are automatically notified of the incident through AIRS and are required to review the incident report within 48 hours of receipt of the report.
7. All incident reports are completed and approved by the regional designated chain of command within 10 working days of receipt of a report.
8. Follow-up reports occur as additional information becomes available.
9. AIRS will be managed by CA Office of Risk Management.

5150. Reviews of Administrative Incident Aggregate Data

1. At least quarterly, statewide program managers designated responsible for management and oversight of administrative incidents conduct an internal review to evaluate occurrences, summarize findings, identify areas for further study, and make recommendations to strengthen practice, programs, and systems. Results of the quarterly statewide review are provided to the appropriate directors.
2. At least quarterly, an internal review of all administrative incidents is conducted by each region and local office. The Office of Risk Management and Division of Program and Practice Improvement provides support and consultation as needed. Summary reports from AIRS are used to evaluate practice and identify trends and strategies to improve outcomes. Results of the local office review are provided to the local office Continuous Quality Improvement (CQI) Standing Team. Results of the regional review are provided to the Regional Management Team.
3. Twice yearly, the Division of Program and Practice Improvement, in partnership with statewide program managers designated with responsibility for management and oversight of administrative incidents publishes a summary report for CA management review that identifies statewide and regional trends.

5160. Administrative Incident Reporting Timelines

5200. CHILD FATALITY REVIEW

1. Purpose

Child Fatality Reviews (CFRs) examine all information provided to the department regarding the child and his or her family. The goals of CFR teams are to:

1. Increase our understanding of the circumstances around a child's death.
2. Evaluate practice, programs and systems to improve the health and safety of children.

RCW 74.13.640

"The Department of Social and Health Services shall conduct a child fatality review in the event of an unexpected death of a minor in the state who is in the care of or receiving services described in chapter 74.13 RCW from the department or who has been in the care of or received services described in chapter 74.13 RCW from the department within one year preceding the minor's death.

Upon conclusion of the child fatality review required pursuant to subsection (1) of this section, the department shall issue a report on the results of the review to the appropriate committees of the legislature and shall make copies of the report available to the public upon request."

For information beyond the scope of this policy see AIRS Companion Guide, Appendix C of this manual.

2. Child Fatality Manner of Death Definitions
1. Unknown/Undetermined: Nature of death is unknown or undetermined at the time of the report.
2. Natural/Medical: Alleged nature of death is Sudden Infant Death Syndrome (SIDS), or otherwise determined to be a natural/medical death, including attended or expected deaths.
3. Accidental: This includes, but is not limited to vehicle accidents, falls, drowning, overlay, and/or any other nature of death that is alleged to have been accidental in nature.
4. Suicidal: Any death alleged to have been suicide by the medical examiner, law enforcement, or attending physician.
5. Homicide by Abuse: Homicide alleged to have been committed by a parent or caretaker acting in loco parentis.
6. Homicide by Third Party: Homicide alleged to have been committed by anyone that was not a parent or acting in loco parentis.
3. Requirements

A CFR is required for an unexpected child fatality when the child is under the age of 18 and one of the following conditions applies:

1. There is an open case on the family or any CA family history within 12 months prior to the fatality. This includes information-only referrals within 12 months preceding the death of the child. Cases only open for adoption support do not meet this criteria, unless there has been another active service provided to the family during the 12 months proceeding the death of the child or the death is believed to be the result of child abuse or neglect.
2. The fatality occurred in a CA licensed, certified, or state-operated facility.
3. The fatality occurred in a home or facility licensed to provide childcare through DCCEL.
4. Types of Child Fatality Reviews and Process
1. Child Fatality Review (CFR)
1. Protocols
1. A CFR is coordinated by the regional CPS program manager.
2. A CFR requires a comprehensive file review by CA staff and may include a multi-disciplinary team.
3. Multi-disciplinary team members could include social workers, licensors, supervisors, area administrators, service providers, tribal representatives, and anyone else deemed relevant to the case by the Regional Administrator (RA) or designee. These individuals should be representative of the child's immediate community, such as school personnel, and medical/mental health providers, and other service providers. The RA or designee may also arrange for interviews with any persons involved with the family or the deceased child, as appropriate.
4. All community review team members must sign confidentiality statements before reviewing CA records or documents.
5. The RA is responsible for tracking the progress and completion of CFRs.
6. The regional CPS program manager or designee reviews the case record within 14 calendar days of receiving notification of the child fatality and provides the RA with a verbal debriefing of the case within 45 calendar days of receipt of the report.
7. The RA or his/her designee must complete the CFR within 180 days of the department receiving a report of the fatality. The CFR is documented in AIRS under the same incident number identified for the Administrative Incident Report.
8. The RA may authorize an extension to the 180-day timeframe. When this authorization is provided, the justification is documented in the follow-up section of the initial incident report in AIRS.
9. Division of Children and Family Services (DCFS), DLR, and DCCEL staff persons assigned to the case assists in gathering and providing case information to the regional CPS program manager for documentation in AIRS prior to the review.
2. Reviews
1. Reviews are to address practice, internal policy issues, contract issues, system issues, as well as recognition for exceptional social work practice. Specific personnel issues/actions are addressed separately and not reported in the review.
2. Reviews identify systemic issues and include recommended strategies and implementation steps.
3. Reviews are used to build community alliances, expertise, and commitments for program improvements, policy, and procedural changes, and improved multi-disciplinary collaboration.
4. Reviews may identify program and system strengths, communication issues, and specific information regarding child mortality.
5. Review recommendations may address the total community child protection system and need not be limited to CA or DSHS programs.
6. Reviews may address individual employee actions and decisions in the specific case under review. Reviews should not name the employee.
3. Reports
1. CFR reports will not be released until the AIRS Review Report is locked indicating that the report has been approved by the appropriate RA.
2. The Office of Risk Management makes CFR reports available to legislative committees and the public, per RCW 74.13.6405:

"Upon conclusion of a child fatality review, the department shall issue a report on the results of the review to the appropriate committees of the legislature and shall make copies of the report available to the public upon request."

3. All reports of the CFR team are public record.
4. Release of information is subject to laws regarding public disclosure and confidentiality. Requests for CFR reports are processed through a disclosure program manager at headquarters.
5. Aggregate information with identifying data, including team recommendations, is disclosed to the public in the annual report.
6. The CA Office of Risk Management will:
1. Provide regular reports from CFRs with summary data to increase social workers' understanding of risks to children.
2. Prepare and distribute a report summarizing team findings and recommendations.
3. Publish child fatality information in the annual Children's Administration Performance Report.
4. Work Plans
1. Upon completion of the CFR, if there are practice or system issues identified during the review process, a formal Fatality Review Work Plan is developed and entered into the AIRS system within 30 days of completion of the review.
2. The RA or designee develops, implements, and follows up on work plans and documents progress in AIRS.
3. The RA submits the work plan to the Assistant Secretary, Director of Field Operations, and the Office Chief of the CA Office of Risk Management.
4. Other Division Directors are provided a copy of the work plan.
5. The Office of Risk Management tracks regional work plans.
2. Executive Child Fatality Review (ECFR)
   (See Appendix E on when ECFR maybe convened)
   1. Protocols
   1. An ECFR is convened by the Assistant Secretary.
   2. The ECFR is a multi-disciplinary team comprised of individuals who have not had involvement with the case.
   3. Participants in the ECFR are appointed by the Assistant Secretary.
   4. An ECFR includes professionals who represent the culture of the community in which the fatality occurred. This would include professionals who can address the specific issues of the case such as service providers, foster parent representatives, children advocates, medical professionals, law enforcement, CA staff persons and may include representatives from the legislature. It is important to have professionals who are representative of the client's ethnic and cultural background.
   5. An ECFR is coordinated by the RA or designee and the CA Office of Risk Management.
   6. The regional CPS program manager or designee reviews the case record within 14 calendar days of receiving notification of the child fatality and provides the RA and the CA Office of Risk Management with a verbal debriefing of the case within 45 calendar days of receipt of the report.
   7. DCFS and DLR staff assigned to the case assist in gathering and providing case information to the regional CPS program manager for documentation in AIRS prior to the review.
   8. In cases where an ECFR is undertaken, a separate CFR is not held.
   9. The RA or designee may arrange for interviews with any persons involved with the family or the deceased child as appropriate for the CFR.
   10. All ECFR participants must sign confidentiality statements before reviewing CA records or documents.
   11. The RA or his/her designee, in coordination with the Office of Risk Management, is responsible for tracking the progress and completion of the ECFR.
   12. The ECFR must be completed within 180 days of the department receiving a report of the fatality. The ECFR is documented in AIRS under the same incident number identified for the Administrative Incident Report.
   13. The Assistant Secretary may authorize an extension to the 180-day timeframe. When this authorization is provided, the justification is documented in the follow-up section of the initial incident report in AIRS.
   2. Reviews
   1. Reviews address practice, internal policy issues, contract issues, and system issues.
   2. Reviews include recommended strategies and implementation steps to address identified issues.
   3. Reviews are used to build or develop community alliances, expertise, and commitments for program improvements, policy, and procedural changes, and improved multi-disciplinary collaboration.
   4. Reviews may identify program and system strengths, communication issues, and specific information regarding child mortality.
   5. Review recommendations may address the total community child protection system and need not be limited to CA or DSHS programs.
   6. Reviews may address individual employee actions and decisions in the specific case under review. Reviews should not name the employee. However, if there are recommendations regarding corrective or disciplinary actions against individual employees, the chairperson will discuss this separately with the RA and the Assistant Secretary and will not include this in the report.
   3. Reports
   1. The regional CPS program manager ensures the issues/recommendations from the ECFR are entered in AIRS under the CFR.
   2. The ECFR report is not released until the AIRS Review Report is locked indicating that the report has been approved by the Office of Risk Management.
   3. The Office of Risk Management in collaboration with the RA shares the ECFR report with the DSHS Secretary, CA Assistant Secretary, CA Division Directors, RAs, and CA Staff.
   4. The Office of Risk Management provides a copy of all reports to the Office of the Family and Children Ombudsman.
   5. The Office of Risk Management makes CFR reports available to legislative committees and the public, per RCW 74.13.6405:

   "Upon conclusion of a child fatality review, the department shall issue a report on the results of the review to the appropriate committees of the legislature and shall make copies of the report available to the public request."

   6. All reports of the CFR team are public record.
   7. Release of information is subject to laws regarding public disclosure and confidentiality. Requests for CFR reports are processed through a disclosure program manager at CA headquarters.
   8. Aggregate information with identifying data, including team recommendations, is disclosed to the public in the annual report.
   9. The CA Office of Risk Management will:
   1. Make available CFR reports to all CA staff persons.
   2. Prepare and distribute documents summarizing team findings.
   3. Publish child fatality information in the annual Children's Administration Performance Report.
   4. Work Plans
   1. Upon completion of the ECFR, if there are practice and system issues identified during the review process, a Fatality Review Work Plan will be developed and entered into AIRS within 30 days of completion of the review.
   2. The Work Plan is based on issues identified in the review. The Regional Administrator or designee in coordination with the Division of Program and Practice Improvement, and the CA Office of Risk Management develops the draft Work Plan.
   3. The Division of Program and Practice Improvement submits the draft Work Plan to the Assistant Secretary for approval.
   4. The approved Work Plan is documented in AIRS by the Office of Risk Management in collaboration with the Regional CPS Program Manager.
   5. Implementation, follow up, and tracking of the Work Plan is done by the Division of Program and Practice Improvement in coordination with the CA Office of Risk Management.
3. Child Death Review (CDR)

The CDR is coordinated by the Department of Health (DOH). It is a multi-agency, multi-disciplinary team of professionals with two purposes:

• To focus on both agency and community responses to the death and possible preventative steps to be taken.
• To consider broader data, such as demographic information and systemic, community responses to the death.
1. CA is represented on the CDR as a full team member. The RA ensures that a representative from CA is assigned to and participates on all DOH teams. A copy of the CFR report (if one has been held) is provided to the team for reviews of children who have died unexpectedly and the family has received CA services within the 12 months preceding the child's death.
2. By statute, the deliberations of the DOH/DSHS fatality review teams are not disclosed (RCW 42.17.31902). Discussions and documents from the CDRs are confidential and cannot be disclosed.

5220. Fatality Review Matrix

Shaded cases require a fatality review. RA has option to request review of any case (e.g. Items 24 & 27)

5230. Administrative Incident Review Activity

5300. INVESTIGATING ABUSE AND NEGLECT IN STATE REGULATED CARE

5310. Introduction

1. The Division of Licensed Resources (DLR) Child Abuse and Neglect Section Practice Guide - Investigating Abuse and Neglect in State-Regulated Care is a "how-to" guide to be used by the facility investigators in the course of investigations of alleged abuse and neglect in state-regulated care.
2. The guide expands the Washington State Risk Assessment Model, developed for investigation of abuse in biological families, to include risk factors specific to state-regulated care. Within the "state-regulated" care sub-group, there are many differences between types of care. The guide helps investigators assess the importance of those differences between types of care, while emphasizing the major similarities that need assessment in the course of an investigation.

5321. Purpose and Scope

1. CA has a responsibility to ensure that high quality care is provided when a child is under state supervision or when a facility providing care is state-regulated. Minimum licensing requirements (MLR) define a higher standard of care than expected and legally allowed in a biological family unit. As a result, standards for accepting referrals for investigation of alleged abuse and neglect in state-regulated care encompass a wider range of allegations than those involving biological family units.
2. Child Protective Service (CPS) investigations of reports of alleged abuse or neglect in licensed, certified, and state-operated care facilities (child day care, foster care, group care, hospitals, and institutional care) have five main goals:
   1. To ensure the immediate safety of alleged child victims;
   2. To investigate allegations and make determinations regarding the existence of child abuse and neglect (CA/N);
   3. To assess whether the child in question has been abused or neglected in a state-regulated setting in ways that have not been alleged;
   4. To identify risk factors within the facility which create a substantial risk of future harm to children; and
   5. To ensure consistency and equity toward providers in the investigation of abuse and neglect.
3. Investigations of alleged abuse or neglect must include assessments of the presence or absence of patterns of CA/N and/or inadequate care as well as documenting specific incidents of child maltreatment.
4. Investigations of alleged abuse or neglect in licensed care are distinct from investigations of compliance with MLR or certification standards. Nevertheless, when there is an investigation of alleged abuse or neglect in licensed care, the investigator must consider a history of compliance or non-compliance with MLRs or certification standards in his or her overall assessment.
5. Investigations of alleged abuse or neglect are expected to result in findings related to specific allegations of CA/N. The findings also include the presence or absence of other abuse or neglect in the licensed setting and record the important risk and protective factors present. Findings must have a strong factual basis, be supported by appropriate documentation, and include recommendations regarding disposition of the case.
6. See the DLR Child Abuse and Neglect Section Practice Guide - Investigating Abuse and Neglect in State Regulated Care for steps to follow for Intake, Investigation, Assessment, and Disposition of allegations of CA/N in state-regulated care.

5400. HEALTH AND SAFETY REVIEWS

CA staff must use the CA protocol Health and Safety Review Standards - Procedures for Group Care and Therapeutic Foster Health and Safety Reviews as the guideline for conducting health and safety reviews of this types of facilities. In addition, staff must comply with the provisions of the CA Practices and Procedures Guide, chapter 4000, section 4421, Health and Safety of Children.