Incident Reporting Policy & Procedure

Participant Support Procedures > Incident Reporting Policy & Procedure

Policy authorised by Board of Management 6 March 2020

Procedure authorised by Chief Executive Officer

Revised Procedure Date: 19 May 2025

Policy statement

Kyeema Support Services ensures that all incidents are acknowledged, investigated, responded to, well managed and learned from.

This policy supports Kyeema Support Services to apply Standard 2: Governance and Operational Management of the NDIS Practice Standards.

Who does this apply to?

This policy applies to all Kyeema workers and their incident reporting requirements, including Occupational Health & Safety (OH&S) incidents whether or not they are participant-related.

Related legislation and policy

The National Disability Insurance Scheme Act 2013

NDIS (Incident Management and Reportable Incidents) Rules 2018

DFFH Client Incident Management System (CIMS) 2019

Occupational Health and Safety Act 2004

Workplace Injury Rehabilitation and Compensation Act 2013

What is reportable conduct under the Reportable Conduct Scheme –Commission for Children and Young People Victoria https://ccyp.vic.gov.au/reportable-conduct-scheme/

Privacy Act 1988

Child Wellbeing and Safety Act 2005

Factsheet: Safety screening requirements from 1 July 2019 DFFH – July 2019

Bus Safety Regulations 2020

Definitions

Workers include employees, contractors and volunteers

Incident an incident is defined as an act, omission, event or circumstance.

It may mean any of the following:

•      Acts, omissions, events or circumstances that occur in connection with providing NDIS supports or services to a person with disability and have, or could have, caused harm to the person with disability

•      Acts by a person with disability that occur in connection with providing NDIS supports or services to the person with disability and which have caused serious harm, or a risk of serious harm, to another person

•      Reportable incidents that have or are alleged to have occurred in connection with providing NDIS supports or services to a person with disability

Near Misses are things that could have caused harm but did not.

Hazard is a source of potential harm to people or a situation with potential to cause injury, loss to property

or equipment or damage to the natural environment.

Reportable Incidents are serious incidents or allegations, which result in harm to a participant. Reportable incidents (including allegations) include:

•      the death of a participant

•      serious injury of a participant

•      abuse or neglect of a participant

•      unlawful sexual or physical contact with, or assault of, a participant

•      sexual misconduct committed against, or in the presence of, a participant, including grooming of the participant for sexual activity

•      unauthorised use of a restrictive practice in relation to a participant

TAC-funded disability supports -What is a serious incident?

A serious incident is where a certain act or event has occurred or is alleged to have occurred, in connection with the provision of TAC-funded disability supports or services and which resulted in harm or has the potential to harm a client.

The meaning of the phrase ‘in connection with’ covers incidents that:

•      may have occurred during the course of supports or services being provided;

•      arise out of the provision, alteration or withdrawal of supports or services; and/or

•      may not have occurred during the provision of supports but are connected because it arose out of the provision of supports or services.

Other relevant authority incident definitions refer to Kyeema Incident Reporting Chart CCF-31

In-house incident reporting procedure for workers (employees, contractors and volunteers)

When an allegation or incident occurs, the worker follows the in-house incident management process. All incidents and allegations are to be reported (refer to the Incident Reporting for Support Workers Poster CCF-30). Allegations of abuse must be reported immediately.

•      Worker provides immediate response to ensure the safety and wellbeing of the impacted person

•      Contact police/emergency services if required

•      If relevant, protect any evidence for use in possible further investigation

•      Report incident to manager/team leader

•      Complete Incident, Complaint, WHS Record Form CCF-65

•      Report injuries in the Register of Injuries book present at all sites

Reporting procedure by team leaders/manager

Initially incidents are recorded and managed through the in-house incident management system using relevant procedures and forms (CCF-65 Incident, Complaint, WHS Record Form). Reportable incidents are managed and responded to by the manager/team leader according to their severity and reported externally to relevant authorities as required

(Refer to Kyeema Incident Reporting Chart CCF-31 for clarification).

•      Provide immediate response to ensure the safety and wellbeing of the impacted person and workers

•      Police/emergency services if necessary

•      Notify impacted persons support person and/or family

•      Team leader / manager complete page 3 of CCF-65 Incident, Complaint, WHS Record Form

•      Document incident on Incident Register

•      Determine if the incident is reportable and proceed to follow procedure for the relevant authority such as:

o  Police – mandatory reporting of child protection

o  NDIS Commission (NDIS participants) online reporting - CCF-29

o  DFFH Critical Incident Management System CIMS (non NDIS participants) online reporting

o  Coroner/police – report a death

o  Child Safety Reporting DFFH, CCF-65, CCF-38

o  Commission for Children and Young People (CCYP) online reporting for child safety allegations against a worker(18 yrs up)

o  OH&S incidents SF-11 poster

o  Office of the Australian Information Commissioner (OAIC) online reporting for confidentiality/privacy data breaches

o  Transport Accident Commission online reporting for serious incidents

o  Incidents involving allegations of worker to participant assault or unexplained injuries CEO/Manager to use the Incident, Complaint, WHS Record Form CCF-65

Some incidents may have to be reported to more than one relevant authority.

Relevant authority reporting requirements (refer to Kyeema Incident Reporting Chart CCF-31)

NDIS Commission (reported by CEO/Manager)

Most reportable incidents must be:

•      notified to the NDIS Commission (Immediate Notification Form available from the online Portal) within 24 hours, and

•      followed up with a detailed report about the incident and actions taken in response within 5 business days.

The unauthorised use of restrictive practice must be:

•      notified to the NDIS Commission within 5 business days, but

•      reported within 24 hours if there is harm to a participant.

A final report may also be required within 60 business days of submitting the 5 day report. The NDIS Commission will advise you whether a final report is required.

Resources:

•      NDIS Process for Notification of Reportable Incidents for Team Leaders & Managers Flowchart CCF-29

•      NDIS Commission Portal - My Reportable Incidents 

Outside of business hours advise the NDIS Commission via email to reportableincidents@ndiscommission.gov.au with an email that includes:

•      The steps taken to complete the authorised notification form and the presenting issue

•      The name of the impacted person

•      Describe the immediate response and step taken to ensure the impacted person was safe

•      Brief description of the reportable incident

•      Whether other authorities, such as the police, were notified

Confirmed case of COVID-19 report to:

•      Notification of event form - COVID-19 (registered providers) https://www.ndiscommission.gov.au/providers/notice-changes-events/notification-covid-19

DFFH CIMS (Critical Incident Management System) (reported by CEO/Manager)

You will need to report via CIMS for any non-NDIS participants.

Major and non-major impact incidents require the completion and submission of a client incident report to the designated divisional office within three business days of the incident occurring or of the service provider becoming aware of the incident (Figure 1). All major impact incidents must be subject to either an investigation and/or a review led by the service provider (see Kyeema Incident Reporting Chart CCF–31 for definitions of major and non-major impact incidents)

•      Critical Incident Management System (CIMS) Incident Reporting https://cims.vic.gov.au/#/introduction

•      Client Incident Management Summary Guide (3)

https://providers.DHHS.vic.gov.au/client-incident-management-summary-guide-word

COVID-19 confirmed diagnosis notify the Department of Health and Human Services DRRG by email DRRG@DFFH.vic.gov.au

Police

Where a reportable incident may constitute a criminal offence or if police attendance is necessary to ensure the safety of those involved in the incident, the incident must be reported immediately to the Victoria Police on 000

Coroner

A ‘reportable death’ to the coroner includes deaths that appear to be unexpected, unnatural or violent or to have resulted, directly or indirectly, from accident or injury. http://www.coronerscourt.vic.gov.au/.

Child Safe Reporting (reported by CEO/Manager)

Where a person believes on reasonable grounds that the reportable incident has child protection implications, NDIS providers will be required to comply with mandatory child protection reporting requirements.

Child (0-17 years) abuse incidents or allegations are reported to

•      Police 000

•      DFFH Child Protection ph. 1800 075 599  (AH 131278)

o  Incident, Complaint, WHS Record Form CCF-65

o  Child Safety Reporting Process Flowchart CCF-38

•      NDIS Commission if the child is a NDIS participant

Child safety allegations made against a worker/volunteer (18 years or older) reportable conduct includes allegations against workers or volunteers of child abuse and misconduct involving children. For example, reportable conduct includes sexual misconduct or offences, grooming, ‘sexting’, inappropriate physical contact with a child or other conduct that crosses professional boundaries concerning children. 

Report to:

•      Police 000

•      Commission for Children and Young People (CCYP)

o  Reportable Conduct Scheme Notification form within 3 business days (reported by CEO) and a 30 day follow up report

o  Notify and update reportable allegations https://ccyp.vic.gov.au/reportable-conduct-scheme/notify-and-update/

o  What is reportable conduct? https://ccyp.vic.gov.au/child-safety/resources/reportable-conduct-scheme-information-sheets#TOC-2

•      NDIS Commission if the child is an NDIS participant

OH&S

For incidents not reportable to WorkSafe, workers are to:

•      Fill in Register of Injuries book present at all work sites

•      Incident, Complaint, WHS Record Form CCF-65

•      Report incident on Incidents Register

•      NDIS Commission for NDIS participant

•      DFFH CIMS for non NDIS participant

WorkSafe Victoria (reported by CEO/Manager)

Refer to Worker Injury Reporting and Notifiable Incidents Procedure

•      Worker Injury Reporting and Notifiable Incidents Procedure

o  Confirm incident reportable

o  Ensure incident scene is not disturbed until an inspector arrives

o  Notify WorkSafe immediately on 132360

o  Report the incident in writing to WorkSafe within 48 hrs

o  Store a copy of the incident notification form securely

•      Issue Resolution Flowchart SF-06

•      WorkSafe incidents online reporting notification form: https://prod.wsvdigital.com.au/sites/default/files/2019-01/FOR-Incident-notification-form-2019-01.pdf

Confirmed COVID-19 Diagnosis

•      Workplaces are no longer required to notify WorkSafe of a confirmed Covid-19 case

•      Workplaces must still adhere to the COVID-19 notification requirements set by the Department of Health, where notice must be given to the department when five positive cases have attended the work premises within seven days.

•      WorkSafe can take action against workplaces that do not comply with their obligations under the Occupational Health and Safety Act.

Office of the Australian Information Commissioner (reported by CEO/Manager)

•      Report incident on Incidents Register

•      Breach of Confidentiality or Privacy Procedure

•      Notifiable Data Breach Form (NDB)  https://forms.business.gov.au/smartforms/landing.htm?formCode=OAIC-NDB

•      NDIS Commission for NDIS participant

•      DFFH CIMS for non NDIS participant

Transport Accident Commission (TAC)

•      Report incident on Incidents Register

•      Complete the Serious Incident Form https://www.tac.vic.gov.au/providers/for-disability-service-providers/serious-incident-form

•      The form is to be submitted to the TAC within 24 hours of the Provider becoming aware of an incident or allegation.

Funds in Court and Commonwealth Continuity of Support participants

•      Report incident on Incidents Register

•      Report critical incidents to emergency services and family

Vehicle Incidents

•      use SF-13 and report incident to reception

Bus Incidents (any bus that is registered to have 10 seats or more)

Bus incident means—

a)  a category 1 incident; or (death, serious accident etc)

b)  a category 2 incident; or (police attend, hospitalised people etc)

c)  a category 3 incident; (alleged assault, suspected harm etc)

Refer to the Bus Safety Regulations 2020 p.2 for incident definitions.

If a bus is involved in an incident that meets the criteria specified in the definition of category 1, 2 or 3 incidents in Bus Safety Regulations (BSR) 2020, the following operational procedure as specified in BSR 2020, Part 8 is to be followed:

1.  The bus driver is to contact On Call and/or Lalor St 55235999 as indicated on the Emergency Response Plan SF-62, which is kept on each bus.

2.  The emergency contact phone number will be the On Call phone number, the ‘responsible person’.

3.  If a category 1 incident, the responsible person will, as soon as possible, contact the TSV Duty Officer on TSV Hot Line 1800 301 151 and provide details of the incident. This number has been installed in the mobile phone.

4.  If a category 1 OR category 2 incident, the responsible person will ensure that within 72 hours of the incident, the online Transport Safety Victoria (TSV) Notification of Bus Incident form at https://transportsafety.vic.gov.au/ is completed.

5.  If a category 3 incident, the Responsible Person will ensure that a report is provided monthly within 5 business days of the last day of each calendar month online, in the form and including the details in the form specified at https://transportsafety.vic.gov.au/

6.  Confirmation of the currency of both the TSV Hot Line number and the Notification of Bus Incident page has been included in the MIS internal audit.

Bus incidents will be investigated by the Operator as follow:

•      If directed by TSV. Investigation is to commence within 7 days after receiving a notification in writing and the report provided to TSV as soon as practicable, or within the period specified in the direction, or within 60 days.

•      The Operator may elect to conduct an investigation without the direction of TSV. (If the operator does this, they will notify TSV and provide them with the report within 60 days of the commencement of the investigation).

Reporting responsibilities

Responsibility for the implementation of this procedure belongs to the CEO, all managers, team leaders, on-call workers and support workers. It is the managers responsibility to ensure that workers are supported to report incidents and that there are no negative consequences in doing so. All online reporting is the responsibility of the CEO/Manager

Record keeping

All documentation relating to the incident or alleged incident (both paper and electronic) is to be kept in a safe and secure place. See CCF-65 for record-keeping finalisation details.

The Incident Register K:\General Items for All Staff\Data Bases\Incident-Register Kyeema must be updated within 24 hours of an incident or alleged incident occurring.

Hard copies of reports are to be filed in the participant’s file. Records of each reportable incident must be kept for seven years.

In all cases, you must provide an assessment of:

•      the impact on the NDIS participant

•      whether the incident could have been prevented

•      how the incident was managed and resolved

•      what, if any, changes are required to prevent further similar events occurring

•      whether other persons or bodies need to be notified.

•      feedback from the participant

Save a copy of the WorkSafe incident notification form for 5 years.

Awareness and training

Information on the incident reporting procedure is available on the QMS, noticeboards and worker training days. Workers are aware of, trained in and comply with the required procedures in relation to incident reporting.

Any significant changes in this policy or process will be advised to workers through the organisation’s intranet and if appropriate, training workshops will be offered.

Complaints

Kyeema service issue complaints refer to Complaints and Feedback Management Policy and Procedure

Complaints about the quality or safety of NDIS supports and services can be made to the NDIS Commission 1800035544

Complaints about the NDIA or participant plans continue to be made to the NDIA or Commonwealth Ombudsman.

Review and Evaluation

The NDIS Commission and/or other relevant authority may take action in response to a reportable/notifiable incident. This may require specified remedial action, carry out an internal investigation about the incident, refer the incident to another body, or engage an expert to investigate and report on the incident.

The CEO/Manager will reflect on the process and decide whether or not corrective action should be taken to improve service quality and delivery of supports and restorative action to repair the relationship with the person with disability.

The CEO will keep the Board of Management informed of any issues relating to critical incidents.  Reportable Incidents will be reported to the NDIS Commission and/or other relevant authorities and the Board will be briefed on responses to any incidents that indicate a need for changes to policies or procedures.

Related policy, procedures and documents

Responding to Allegations of Abuse, Neglect and Exploitation Policy|topic=Responding to Allegations of Abuse\, Neglect & Exploitation Policy

Child Safety and Wellbeing Policy & Procedure|topic=Child Safety and Wellbeing Policy & Procedure

Worker Injury Reporting and Notifiable Incidents Procedure|topic=Worker Injury Reporting and Notifiable Incidents Procedure

Privacy and Confidentiality Policy and Procedure|topic=Privacy and Confidentiality Policy and Procedure

Confidentiality and Notifiable Data Breaches|topic=Confidentiality and Notifiable Data Breaches

Pandemic & Epidemic Contingency Procedure|topic=Pandemic & Epidemic Contingency Procedure

Complaints and Feedback Management Policy and Procedure|topic=Complaints and Feedback

Exit from Funded Supports Procedure

Management of waste Policy & Procedure

Report a Hazard SF-11

Vehicle Incident Form SF-13

Restrictive Practices Register BF-09

Exit from Service Form CCF-06

Indicators of Violence, Abuse, Neglect, Exploitation & Discrimination CCF-24

Child Safety Reporting Process Flowchart CCF-38

NDIS Process for Notification of Reportable Incidents (Team Leaders/Managers) Flowchart CCF-29

Incident Reporting for Support Workers Poster CCF-30

Kyeema Incident Reporting Chart CCF-31 (for team leaders/managers)

Restrictive Practices Register BF-09

Incident, Complaint, WHS Record Form CCF-65

Issue Resolution Flowchart SF-06

Responding to Allegations of Abuse Flowchart KEF-46

Emergency Response Plan SF-62

Debrief After Unauthorised Restrictive Practice BF-04

URP Incident Report Form for APO / Team Leaders BF-07