4501 Dhsr Hcpr Form PDF Details

Ensuring the safety and well-being of residents in healthcare settings is a cornerstone of effective health service regulation, a principle that the 4501 DHSR HCPR form stands testament to. Issued by the North Carolina Department of Health and Human Services, this form serves as a critical tool for reporting allegations against health care personnel. It mandates that all allegations, including those injuries of an unknown source which might suggest resident abuse or neglect, be reported within a strict 24-hour timeline. Furthermore, the form sets forth requirements for reporting suspicions of crimes, delineating a two-hour window for incidents leading to serious bodily injury and a 24-hour window for those without. Details such as provider information, incident specifics, resident and accused individual information are methodically captured to facilitate thorough investigation and response. The form is a stark reminder of the legal and moral obligation healthcare facilities have towards ensuring a safe and abuse-free environment for their residents. Adherence to the procedures outlined in this form not only aligns with state statutes, including NC Gen. Stat. §131E-256(g) and federal regulations outlined in 42 U.S.C. 1320b-25 but also underscores the healthcare community's commitment to transparency, accountability, and resident safety. Compliance is enforced through the requirement of a follow-up investigation report within five working days, emphasizing the urgency and seriousness with which these matters are to be treated.

QuestionAnswer
Form Name4501 Dhsr Hcpr Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshour report, hcpr 24 hour initial report, dhsrhcpr from, 24 hour report

Form Preview Example

N.C. Department of

Health Care Personnel Registry

FAX: (919)

733-3207

Health & Human Services

24-HOUR INITIAL REPORT

Phone: (919)

855-3968

Division of Health Service

2719 Mail Service Center

 

Regulation

Allegation Report by Facility/Provider

Raleigh, NC 27699-2719

All allegations against health care personnel, including injuries of unknown source which appear to be related to resident abuse or neglect, must be reported to the HCPR within 24-hours. [see NC Gen. Stat. §131E-256(g)]

Certain providers must report a reasonable suspicion of a crime with resulting serious bodily injury within 2-hours, and a reasonable suspicion of a crime without resulting serious bodily injury within 24-hours. [see 42 U.S.C. 1320b-25]

 

 

Provider Information

 

County:

 

 

 

Facility/

 

 

 

 

 

 

 

 

 

 

 

 

Provider Type:

 

 

 

 

 

 

 

 

 

 

Facility/Provider Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

National

 

 

 

 

 

 

Facility/Provide

 

 

Provider

 

 

 

 

 

 

r License #:

 

 

 

#:

 

 

Other ID #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Administrator/

 

 

 

Main Office

 

 

 

 

Main Office

 

 

 

 

 

 

Director

 

 

 

 

 

 

 

 

 

Phone #: (

)

 

 

 

(Secure) Fax #: (

)

 

 

 

Email Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Person:

Mr.

Ms.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Title:

 

 

 

 

Administrator:

Mr.

Ms.

 

 

 

 

 

 

 

 

 

 

 

 

 

Title:

 

 

 

MAIN OFFICE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

State:

 

Zip:

 

ACTUAL INCIDENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Location Address:

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

State:

 

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Allegation/Incident

 

 

 

REASONABLE SUSPICION OF A CRIME (Explain

Is reasonable suspicion of a crime related to any

 

Type

 

 

 

 

 

 

 

 

 

under “Allegation/Incident Details” below)

 

 

allegation checked below?

Yes

No

 

(check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RESIDENT ABUSE

 

 

 

 

 

DIVERSION OF FACILITY DRUGS

 

MISAPPROPRIATION OF FACILITY PROPERTY

 

 

 

 

 

 

 

 

 

 

 

RESIDENT NEGLECT

 

 

 

FRAUD AGAINST RESIDENT

 

 

MISAPPROPRIATION OF RESIDENT PROPERTY

 

 

 

 

 

 

 

 

 

 

DIVERSION OF RESIDENT DRUGS

 

FRAUD AGAINST FACILITY

 

 

INJURY OF UNKNOWN SOURCE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Allegation Description

Incident Date:

 

Time:

a.m.

p.m.

Description of Physical or Mental Injury/Harm:

Resident Information

Resident’s Type of

Care/ Service & Setting:

Resident

 

Date of

Full Name:

Mr. Ms.

Birth:

(Examples - Home Care, Nursing Home, Hospital/Acute Care, Day Program, CAP, CBS, Substance Abuse, Respite, etc.)

 

 

Accused Individual Information

Full Name:

Mr.

Ms.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of

 

 

 

Job Title:

 

 

 

 

 

Hire:

 

Date of Birth:

 

Social Security #

 

 

 

 

 

 

Taxpayer ID # or

 

 

(required):

 

 

 

 

 

 

other ID #:

 

 

Last Known

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

City:

 

State:

Zip:

Home Phone #: (

)

 

 

 

Other Phone # (Cell phone, work, etc.): (

)

 

 

 

 

 

 

Is there a Reasonable

 

 

Is there Serious

 

 

 

 

Law Enforcement

 

Yes

No

Yes

No

 

 

 

 

Suspicion of a Crime?

Bodily Injury?

 

 

 

 

 

Time

Incident reported to law enforcement?

Name of law enforcement agency:

Yes

No

Date reported:

Reported:

Investigating Officer:

Phone #: (

)

 

 

 

 

INVESTIGATION REPORT MUST FOLLOW WITHIN 5 WORKING DAYS

 

The results of all investigations must be reported within five working days of the initial notification to the department. [see NC Gen. Stat. § 131E-256.(g)]

Failure to comply may result in a report to the agency having jurisdiction for compliance enforcement.

DHSR/HCPR Form No. 4501 Rev. 06/24/2014

Additional information available at www.ncnar.org

(Print Name and Title of Person Preparing Report)

(Signature of Person Preparing Report)

(Date Signed)

DHSR/HCPR Form No. 4501 Rev. 06/24/2014

Additional information available at www.ncnar.org

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Be mindful while filling in this form. Make certain each and every field is done correctly.

1. The nc initial report necessitates specific information to be typed in. Make certain the following fields are finalized:

Stage number 1 for completing dhsr report

2. Once this part is filled out, proceed to type in the relevant information in all these: DIVERSION OF RESIDENT DRUGS, FRAUD AGAINST FACILITY, INJURY OF UNKNOWN SOURCE, Allegation Description, Incident Date, Time, Description of Physical or Mental, Resident Information Residents, Resident, Full Name, Date of Birth, Examples Home Care Nursing Home, Accused Individual Information, Job Title Social Security , and Home Phone .

Completing part 2 in dhsr report

Always be really attentive while completing Full Name and Incident Date, since this is where most users make some mistakes.

3. In this specific stage, check out Law Enforcement, Is there a Reasonable Suspicion of, Yes, Is there Serious Bodily Injury, Incident reported to law, Yes, Date reported, Name of law enforcement agency, Investigating Officer, Yes, Time, Reported, Phone , The results of all investigations, and INVESTIGATION REPORT MUST FOLLOW. All these have to be completed with greatest precision.

Stage # 3 for filling in dhsr report

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How to prepare dhsr report part 4

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Step number 5 of completing dhsr report

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