The Commonwealth of Massachusetts

Executive Office of Health and Human Services
Department of Public Health
Bureau of Health Care Safety and Quality
99 Chauncy Street, 11th Floor, Boston, MA 02111
617-753-8000

DEVAL L. PATRICK
GOVERNOR
TIMOTHY P. MURRAY
LIEUTENANT GOVERNOR
JUDYANN BIGBY, MD
SECRETARY
LAUREN A SMITH MD, MPH
INTERIM COMMISSIONER	

CIRCULAR LETTER:  DHCQ 13-4-588

TO:		Hospital Chief Executive Officers 
                          
FROM:  	Madeleine Biondolillo, MD
			Director, Bureau of Health Care Safety and Quality

DATE:		April 22, 2013

RE:	Transition to web-based reporting of incidents using the Health Care Facility Reporting System (HCFRS).  

The Department of Public Health, Bureau of Health Care Safety and Quality is pleased to share with you our Health Care Facility Reporting System (HCFRS).  HCFRS is a web-based IT system designed to support and streamline the process of reporting Health Care Facility incidents.  The Health Care Facility Reporting System (HCFRS) has been used successfully for several months (almost 1 year) by over 90% of Massachusetts Long Term Care facilities.

The system provides:
•	A straight forward reporting mechanism 
•	Timely communication with Intake staff to clarify issues, ask questions etc online
•	Useful work flow reminders of the status of the report
•	A means of attaching additional information to preliminary reports
•	A reduction in paper use 

Transition to HCFRS will be required by June 30, 2013.  If your organization has not already enrolled, all paperwork should now be submitted to the Virtual Gateway by May 15, 2013 to ensure the enrollment process is complete by June 30, 2013.  Full guidance on this enrollment process is attached to this Circular Letter.

Secure use of HCFRS is ensured by the Virtual Gateway (VG), the secure internet portal of the State’s Executive Office of Health and Human Services.  Individual accounts need to be established for your facility and each satellite facility in both the VG and HCFRS environments.  Instructions on how to establish an account are attached to this Circular Letter along with definitions and helpful hints on using the system and creating a report.

Should you have any questions regarding this notification, please see the contact details in the attachments to this Circular Letter.

HCFRS enrollment process

The following steps are involved in establishing accounts.  Please note that Appendices A and B mentioned below are considered by the Virtual Gateway to be Legal Documents and therefore the originals must be mailed to DPH. DPH will review these forms to ensure they are complete and forward them to the Virtual Gateway.
          
1.	Fulfillment of Legal Agreements with the Virtual Gateway. 

It is the responsibility of the facility’s Administrator to ensure that the facility is in compliance with Virtual Gateway requirements by completing the Virtual Gateway Service Agreement form (referred to as Appendix B)

2.	Designation of “Access Administrator” 

By completing the document known as appendix A, the facility’s Administrator designates a staff member at the facility to be responsible for signing up the facility’s HCFRS users – this person is known as the Access Administrator. The Access Administrator does not have to be the facility Administrator.  It is advisable to also designate a back up Access Administrator.  The facility’s Administrator must sign both page 1 and page 2 of Appendix A to authorize the Access Administrators.  It is imperative that on both the Appendix A and B forms the name of the facility be consistent throughout the document.  This name is how the Virtual Gateway will recognize a particular facility going forward.  Note:  If the legal entity name and facility name are different, please include both the legal name and the doing business as (dba) name for example DPH Inc, dba DPH (Boston).

Mail the fully completed and original signed appendix A&B Forms to:
HCFRS Enrollment
DPH/Bureau of Health Care Safety & Quality 
99 Chauncy St., 3rd Floor
Boston, MA  02111  	

3.	Agreements with DPH

Facility User and Authorized User Agreement forms, referred to as Form 1 and Form 2, are the agreements with DPH designating the Access Administrator and listing the end users (these should be the same people named in the VG agreements). The Facility and Authorized User Agreement forms should be scanned and emailed to Christina Scimone at HCFRSenrollment@state.ma.us .

4.	Establishing VG “end users”

DPH will notify the Access Administrator at a particular facility when the facility’s account has been established by the Virtual Gateway.  DPH will then email a User Request Form (URF) to the Access Administrator along with instructions for completing and submitting this form.  This URF form will establish end users for a particular facility in HCFRS through the Virtual Gateway and must be sent directly to the Virtual Gateway.  

When the URF form is received by the Virtual Gateway it will be acknowledged. Seven to ten days later the Virtual Gateway will contact the Access Administrator and provide a User I.D. for the facility by email. 

At the same time DPH will approve and upload all end users into HCFRS as the final step.  The HCFRS Facility User Agreement form and the HCFRS Authorized User Agreement form (see 3 above) must have been received by DPH for this upload to occur.
       
Please note, by signing the enrollment application you have agreed to the HCFRS Terms and Conditions.

It is important to note that the Virtual Gateway requires forms to be completed accurately.  Applications received with missing information will therefore be returned.  Unfortunately, this will delay enrollment in the HCFRS program.

Please be aware that it can take two or more weeks from the time that we receive your application to when the HCFRS account will be available to you.

All the forms mentioned above can be found at:

http://www.mass.gov/eohhs/provider/reporting-to-state/abuse-neglect/health-care-facilities/forms-and-web-based-reporting.html   
or by going to the DPH website and clicking on the “Provider” tab following the links to “Forms and Applications”; “Health Care Quality”; and “Reporting Incidents in Healthcare Facilities”.
Information on how to submit an incident using HCFRS, including training videos, is also available on the website. 

We appreciate your participation in the implementation of HCFRS.  If you have questions, please contact: 

        Technical Support                      Guido Altomonte at 617-753-8180 or guido.altomonte@state.ma.us    
        Other Reporting queries             Rosalind Cresswell at 617-753-8159 or rosalind.cresswell@state.ma.us 

Helpful Hints

These hints have been written with the benefit of 6 months experience by users and are offered in an attempt to support facilities in their use of the system.  The more relevant detail and background information you can provide about an incident, the better to illustrate what occurred, how it has been investigated, what the results of the investigation are and what is being done to remedy the situation.

System management
HCFRS has a time out function for security reasons.  Always remember to save data regularly so that it is not lost.

To create a report do not double click to open the Intake function as it will result in the report being opened in read only mode and none of your data can be saved.  Instead use the “available action” drop down function, highlight the action you wish to take and then click “start action”.  The report form screen will then appear.  As a checking mechanism always ensure the save button is highlighted on the report form screen before entering data because if it is not, you will not be able to save what you have typed.

Throughout the report form there are “add new” functions (in blue) which should be used, for example, for submitting multiple residents in resident to resident altercations or for additional harm types etc. relevant to the incident reported.  

If using the tab function to move between fields on the form, the drop down functions do not appear.  For accessing the drop down function use the mouse to scroll between fields.

Once a report is submitted, your initial 9 digit reference number (starting with 1000) will change to a 7 digit number beginning with your facility ID number.  This is your confirmation that the report has been submitted.

Once the report is submitted information cannot be added to the original report.  If you wish to add information you can:
•	For small additional notes use the note box function at the top right of the dashboard (the first page before the report screen) which can also be used for dialogue with DPH and is visible to both parties.
•	For longer comments or copying documents like a care plan, final conclusion or statement use the attachment function located on the left of the dashboard and click add.  Once saved, the attachment is available to DPH to review.
At this time we are working on ways to simplify this process but for now please alert DPH by phone (referencing the report’s incident number) if you are submitting additional information which we have not requested.

If DPH requires additional information on a report you will receive an email from Virtual Gateway alerting you to check the submitted report.  To ensure you receive this email, add the address to your safe sender list - hcq.intake@massmail.state.ma.us.

Content management
Completing the incident narrative
To avoid time spent duplicating information, include only information not covered elsewhere in the report form but please provide full details of the allegation made or incident – including specific details about what was allegedly said/heard/witnessed or what happened and who was involved etc.  If you refer to safety measures please specify whether they were in use, used appropriately and working. 

Completing the internal investigation narrative
 Include details of how you have investigated, what has been determined, whether there are contributory factors, whether similar incidents have occurred and what your conclusions are.  Please explain the reasons for these conclusions or if you are unable to reach a conclusion.

Completing the corrective measures narrative
Include all action taken in response to the incident or allegations, the resident’s current status, any disciplinary action (if taken), checks made to equipment/facility, the plan of correction and changes to care plan including details etc.

Please do not include proper names in your narrative.  Instead refer to “the resident” or “resident #1” etc if there are multiples.

Ensure that all questions on the form are completed as fully as possible including using more than one option from a drop down menu when applicable and available.  For example a resident can be demented and mentally ill.

If information is unknown at the time of completing the report use either the unknown option in a drop down menu or, if none of the available options apply please explain in the report narrative section.

If the report is an initial report and you intend to send additional information, please make this clear in the narrative.  Additional information should be sent as an attachment to the original report and not by creating a new report.  If you indicate that your investigation is on-going, DPH will await a copy of the final report to be attached within usual regulatory time limits.

For accused information the name is required regardless of the outcome of the facility’s investigation.

Please remember that the more information you include and the clearer it is written the less likely we will need to contact you for additional material.  

Thank you for your participation in HCFRS. This data is very important to all of us and contributes to the shared goal of maintaining and raising standards of care provided to residents in Massachusetts LTC facilities.
DEFINITIONS / HIGHLIGHTS

December 1, 2012		Deadline for submission of all enrollment paperwork

January 1, 2013		Facilities will be required to report via HCFRS by this date.

HCFRS	Health Care Facility Reporting System, to replace currently used faxed reporting forms for incidents and allegations.

VG	Virtual Gateway, secure internet portal that facilities are required to establish an account with in order to use HCFRS.

Access Administrator	Designee by facility administrator who is responsible for signing up the facility HCFRS end users. The facility administrator may designate him/herself if desired. 

End Users	Facility staff members who will be able to access and enter reports in the HCFRS.

Appendices A & B	First forms to be submitted, as originals, to DPH. Appendices A&B are available on the website listed on the enclosed circular attachment.

URF	User Request Form. Emailed by DPH to the facility Access Administrator after the VG establishes an account based on receipt of completed Appendix A & B forms. The facility will identify its end users on the URF which is then returned directly to the VG. The VG will email the Access Administrator with the User ID 7-10 days later. 

Facility User (section 1 form)	Emailed by DPH to the facility Access Administrator. Once
          &	completed, these two forms should be scanned and emailed
Authorized User                     to linda.casaletto@state.ma.us 
Agreement (section 2 forms)