Sentinel Event

Policy & Procedure Manual


An event that results in an unanticipated patient death or permanent loss of function not related to the natural course of the patient's illness or underlying condition.

POTENTIAL CONTRIBUTING FACTORS as a result of inadequate:

  1. staff orientation or training
  2. staff competency or level of training
  3. patient assessment process
  4. equipment
  5. communication
  6. physical environment
  7. information
  8. supervision
  9. control/storage of medications


The agency identifies sentinel events and appoints a committee, lead by me Administrator, to conduct a systematic investigation to identify the root cause of the event in order to prevent or reduce the risk of a reoccurrence.


  1. Staff are instructed to report incidents and accidents as soon as possible to their coordinator/supervisor and to complete, appropriate reports.
  2. Reports, verbal and written, are followed-up by the appropriate supervisor, serious or potentially serious ones are reported to the Administrator/Supervisor immediately.
  3. Incident/accident reports are monitored by the Administrator who is responsible for:
    1. identifying sentinel events,
    2. initiating the investigation process, and
    3. determining along with the other members of the Board of Directors when an  attorney is to be involved.
    4. Instructing those involved that all information prepared in relation to the sentinel event report and investigation is to be labeled "Client-attorney work product" to protect confidentiality and is to be kept by the Administrator in a secure place.
  4. The QI/A Committee members are informed and may be included in the process.
  5. The Administrator initiates the "root cause analysis" process which includes:
    1. The team is appointed and responsible for;
      • drawing a cause and effect diagram to display the problem and as many proximate and underlying causes as possible,
      • identifying where protections/barriers against the event failed (Barrier Analysis), and
      • identifying changes winch have occurred between the expected and  actual performance.
    2. The team "brainstorms" about the most likely contributing causes.
    3. Brainstorming is followed by attempts to identify the actual cause(s) of the event and determine if it is a "special" cause or "coninion" cause. Various activities may be used: reviewing policies and procedures, interviewing staff, consulting expert materials and/or individuals, observing specific procedures being carried out, reviewing inservice/training materials,
    4. etc.
    5. As soon as possible causes are identified and data analyzed, a review of the  processes that may have caused the event are made, redesigned, and implemented, as indicated, to prevent recurrence.
    6. Implementation may include all or part of the following interventions:
      1. writing or revising agency policies,
      2. developing or revising agency procedures,
      3. inservice and/or training programs
      4. agency wide meetings and/or memos
      5. developing or revising agency forms
      6. staffing adjustments
      7. pilot or agency wide changes
  6. The Administrator monitors the implementation processes, the outcomes and initiates redesigns as indicated. Tills process is to be completed within six months from the initial intervention.
  7. Although the goal is not to place blame on an individual, me analysis process may identify that an individual's performance was the cause of the event, m which case the agency and or the licensing/credentialing authority take appropriate action. The agency may terminate the individual, make a report to the legal/police authority, etc.

NY Metro Service Area

Our nurses, aides, therapists, and social workers are caring for patients in all of the boroughs of NY city and the surrounding region including:

  • Manhattan
  • Queens
  • Brooklyn
  • Bronx
  • Staten Island
  • Nassau County

We provide service 24 hours a day, 7 days a week.

In Home Evaluation

Every patient has different needs and situation. It is important to have a qualified professional help decide the services needed. Take advantage of our no-cost, no-obligation patient needs assessment.

  • We come to you to evaluate the patient's needs in the home setting.
  • We bring all the forms necessary, and handle insurance and medicaid processing.
  • It costs you nothing.
  • Please fill out our pre-assessment form or call

718 499 6066

to shedule a free no obligation appointment in the home

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Multilingual Staff

We have many nurses and aides on staff that are multilingual. We recognize that communication is key to quality health care, so we will be sure to send staff that can communicate with the patient and family and understand all the patients needs. We have staff members that speak: 

  • English
  • Spanish
  • French
  • Italian
  • Cantonese (Chinese)
  • Mandarin (Chinese)
  • Creole

Specially Trained Staff

Our staff is trained to provide care patients with special needs such as:

  • Geriatric Care
  • HiV/AIDS
  • Palliative Cancer Care
  • Psychiatric Care
  • Dialysis Care
  • Rehabilitative Care

We Accept These Plans & Programs

We have experience with approval and billing management for all third party pay arrangements. Our payment staff will help organize and expedite the application process, and we'll get caring staff providing service as the approval process progresses. We accept:

  • Insurance
  • Worker's Compensation
  • No Fault
  • Disability
  • Managed Care
  • Private Pay