Dhhs Incident Report Form PDF Details

The Department of Health and Human Services (DHHS) requires all organizations who work with or care for children to complete an incident report form whenever an incident occurs. The DHHS incident report form is used to document the specifics of any incidents that occur, including what happened, who was involved, and what steps were taken to resolve the situation. Completing this form is a critical part of ensuring the safety of all individuals involved. Here we will provide a brief overview of the DHHS incident report form, including how to complete it correctly.

QuestionAnswer
Form NameDhhs Incident Report Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesincident form dhhs usda, north carolina incident report form, nc dhsr incident report forms, dhhs incident report

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North Carolina Department of Health & Human Services –Mental Health/Developmental Disabilities/Substance Abuse Services

DHHS Incident and Death Report

Provider Agency Name

Consumer’s Name

LME Client Record Number.

This form is used to report Level II and Level III incidents, including deaths and restrictive interventions, involving any person receiving publicly funded mental health, developmental disabilities and/or substance abuse (MH/DD/SA) services. Facilities licensed under G.S. 122C (except hospitals) and unlicensed providers of community-based MH/DD/SA services must submit the form, as required by North Carolina Administrative Code 10A NCAC 27G .0600, 26C .0300, and 27E .0104(e)(18). Failure to complete this form may result in administrative actions against the provider’s license and/or authorization to receive public funding. This form may also be used for internal documentation of Level I incidents, if required by provider policy or LME contract. Effective May 1, 2010, this form replaces the DHHS Incident and Death Report (Form QM02, Revised April, 2009).

Instructions: Complete and submit this form to the local and/or state agencies responsible for oversight within 72 hours of learning of the incident (See page 3 for details). Report deaths of consumers that occur within 7 days of restraint or seclusion immediately.

If requested information is unavailable, provide an explanation on the form and report the additional information as soon as possible.

Page 1-2 Instructions: The staff person who is most knowledgeable about the incident should complete pages 1-2 of this form as soon as possible after learning of the incident and submit to their supervisor or other staff as directed by agency policy) for review and approval.

Date of Incident:

 

Time of Incident:

a.m.

p.m.

Unknown

CONSUMER INFORMATION

Consumer’s Date of Birth:

 

 

 

 

 

 

Consumer’s Gender:

Male

Female

 

 

 

 

 

 

All Diagnoses:

 

 

 

 

 

 

Consumer enrolled in Methadone maintenance program?

Yes

 

 

 

 

 

 

 

 

 

 

 

Consumer enrolled in one of the following CAP/MR-DD

 

 

Consumer adjudicated incompetent?

Yes

No

 

 

Waiver services? Check all that apply:

 

 

 

 

 

 

Consumer has TBI (Traumatic Brain Injury)?

Yes

No

 

 

 

Comprehensive Waiver

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Consumer receiving ICF-MR/DD Services?

Yes

No

 

 

 

Supports Waiver

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Money Follows the Person

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Innovations

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RACE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hispanic/Latino

Native American

White/Anglo

 

 

 

 

 

 

 

 

 

 

 

Black/African American

Mixed Race

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION OF INCIDENT

 

 

 

 

 

 

 

 

 

INCIDENT

 

Community

Consumer’s legal residence

 

Day Treatment

Family’s home

Friend’s home

 

Hospital

 

 

 

 

Name / title of first staff person to learn of incident

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider premises

Unknown

Other (specify)

 

 

 

 

 

 

 

 

 

 

OF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was the consumer under the care of the reporting provider at the time of the incident?

 

Yes

No

 

 

 

 

 

 

DESCRIPTION

 

 

 

 

 

 

 

 

 

Was the consumer treated by a licensed health care professional for the incident?

 

Yes

No

Date:

 

 

 

 

 

 

Was the consumer hospitalized for the incident?

 

 

 

 

 

Yes

No

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: Incident reports are quality assurance documents. Do not file incident reports in the consumer’s service record. Confidentiality of consumer information is protected. Use the form according to confidentiality requirements in NC General Statutes and Administrative Code and the Code of Federal Regulations.

DMH/DD/SAS-Community Policy Management Section – Guide for Form QM02

Effective October, 2004 – Rev. 05/2010

Page 1 of 4

North Carolina Department of Health & Human Services –Mental Health/Developmental Disabilities/Substance Abuse Services

DHHS Incident and Death Report

Provider Agency Name

Consumer’s Name

LME Client Record Number.

 

Briefly describe the incident, including Who, What, When, Where, and How. Do not provide another consumer’s name or identifying

 

information.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONSUMER DEATH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Level II death due to:

Terminal illness/natural causes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Level III death due to:

SUICIDE

ACCIDENT

 

HOMICIDE / VIOLENCE

UNKNOWN CAUSE

 

 

 

 

 

 

 

 

Did death occur within 7 days of the restrictive intervention?

 

Yes

No If yes, immediately submit this form to your supervisor.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DETAILS OF DEATH REPORTABLE TO NC DEPARTMENT OF HEALTH & HUMAN SERVICES

 

 

 

 

 

 

Complete this section only for deaths from suicide, accident, homicide/violence, unknown cause or occurring within 7 days of restrictive

 

 

 

intervention.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address where consumer died:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

County_____

 

 

INCIDENT

 

Physical illnesses / conditions diagnosed prior to death:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dates of last two (2) medical exams:

 

 

 

 

 

 

 

 

 

 

 

 

Unknown

None

 

 

 

 

 

 

 

Date of most recent admission to a hospital for physical illness:

 

 

 

 

 

Unknown

None

 

 

 

 

 

OF

 

Date of most recent discharge from a hospital for physical illness:

 

Unknown

None

 

 

 

 

 

 

Date of most recent admission to an inpatient mh/dd/sas facility:

 

 

 

 

 

Unknown

None

 

 

 

 

 

TYPE

 

 

 

 

 

 

 

 

 

 

 

 

Date of most recent discharge from an inpatient mh/dd/sas facility:

 

Unknown

None

 

 

 

 

 

 

 

Height:

 

 

ft

 

in

Unknown

 

Weight:

 

 

 

 

lbs

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RESTRICTIVE INTERVENTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did death occur within 7 days of the restrictive intervention?

 

Yes

No If yes, immediately submit this form to your

 

 

 

 

 

 

supervisor.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Number in order of use)

 

Is the use of restrictive intervention part of the consumer’s Individual Service Plan?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical Restraint

 

Was the restrictive intervention administered appropriately?

 

Yes

No

 

 

 

 

Isolation

 

 

 

 

 

 

 

 

 

 

 

Did the use of restrictive intervention(s) result in discomfort, complaint, or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Seclusion

 

require treatment by a licensed health professional?

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attach a Restrictive Intervention Details Report (Form QM03) or a provider agency form with comparable information.

NOTE: Incident reports are quality assurance documents. Do not file incident reports in the consumer’s service record. Confidentiality of consumer information is protected. Use the form according to confidentiality requirements in NC General Statutes and Administrative Code and the Code of Federal Regulations.

DMH/DD/SAS-Community Policy Management Section – Guide for Form QM02

Effective October, 2004 – Rev. 05/2010

Page 2 of 4

North Carolina Department of Health & Human Services –Mental Health/Developmental Disabilities/Substance Abuse Services

DHHS Incident and Death Report

OTHER INCIDENT

 

 

 

INJURY

ABUSE ALLEGATION

 

 

 

MEDICATION ERROR

 

 

 

 

 

Report injuries requiring treatment by a

(Check all that apply)

Report errors that threaten health or safety

 

 

 

licensed health professional

Alleged abuse of a consumer (includes

 

 

 

(Check all that apply)

 

 

 

 

 

 

 

 

 

sexual abuse)

 

 

 

 

 

 

 

 

(Check only one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wrong dose administered

 

 

 

 

 

Injury due to:

Alleged neglect of a consumer

 

 

 

 

 

Alleged exploitation of a consumer

 

 

 

 

 

 

 

 

 

 

 

 

 

Assault

Wrong medication administered

 

 

 

 

 

Alleged sexual abuse of a consumer

 

 

 

 

 

Motor vehicle accident

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wrong time (administered more than one

 

 

 

Self-injury

 

 

 

 

 

Report any alleged or suspected case of

hour before or after prescribed time)

 

 

 

 

 

Suicide attempt

 

 

 

 

 

abuse, neglect or exploitation of a

 

 

 

 

 

 

 

 

 

 

 

 

 

Trip or fall

Missed dose

Refused dose

 

 

 

 

 

consumer, as required by law, to the

 

 

 

 

 

Other (specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

county Dept. of Social Services and the

Medication given to wrong consumer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DHSR Healthcare Personnel Registry (if a

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

staff is accused).

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONSUMER BEHAVIOR (Check all that apply)

 

 

 

 

 

 

OTHER INCIDENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Check only one)

 

 

 

 

 

Aggressive behavior

 

 

 

 

 

 

Suspension of a consumer

 

 

 

Destructive behavior

 

 

 

 

 

from services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Illegal act

 

 

 

 

 

Number of days suspended

 

 

 

 

 

Inappropriate or illegal sexual behavior (consumer is victim, not perpetrator)

 

 

 

 

Expulsion of a consumer from

 

 

 

Unplanned consumer absence of more than 3 hours over the time specified in person- centered plan

 

 

services

 

 

 

 

 

Diversion of drugs

 

 

 

 

 

 

Fire that threatens or impairs a

 

 

 

Other (specify)

 

 

 

 

 

 

consumer’s health or safety

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name/title of staff person documenting incident (Please print):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone (

)

 

 

 

 

 

 

Signature ________________________________________________________ Date

 

 

Time

 

 

a.m.

p.m.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supervisor’s Instructions: The supervisor of the service should review pages 1-3 of this form, complete pagse 3 and 4 and submit to required agencies in the required timeframes.

PROVIDER

INFORMATION

 

 

Facility / Unit

 

 

 

 

Facility /Unit Director:

 

 

 

 

 

 

Service address:

 

 

 

 

City:

 

 

 

 

County

 

Facility /Unit Phone Number: (

)

 

IPRS Billing No. or National Provider ID No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

Service being provided at time of incident:

Residential

Licensed Residential License No________

 

Non-residential (specify)

 

 

 

 

 

 

 

 

Was a 122C-Licensed service being provided at the time of the incident?

No

Yes (License No.)

 

 

 

If yes, note

reporting instructions for Level III below.

 

 

 

 

 

 

 

 

 

 

 

 

LEVEL OF INCIDENT

Level II (Moderate)

Send this form to the host LME (LME responsible for geographic area where service is provided) within 72 hours. If required by contract, also report to the consumer’s home LME.

Level III (High)

Immediately report verbally to the host LME. Convene an incident review committee within 24 hours if services were being actively provided at time of incident or the incident occurred on the provider’s premises. Send this form within 72 hours to:

host LME (see bottom of page)

consumer’s home LME

NC Division of MH/DD/SAS, Quality Management Team, 3004 MSC, Raleigh, NC 27699-300

Voice: (919) 733-0696 Fax: (919) 508-0986

NOTE: Report deaths that occur within 7 days of seclusion or restraint immediately to the host LME and DMH/DD/SAS Advocacy Team (919) 715-3197.

NOTE: If a licensed G.S.122C service was being provided at time of the Level III incident, use the same deadlines to report death from suicide, accident, homicide/violence, and death occurring within 7 days of restraint or seclusion, to the NC Division of Health Service Regulation, Complaint Intake Unit, 2711 MSC, Raleigh, NC 27699-2711. Voice: 1-800-624-3004 Fax: 919-715-7724

Do not report deaths of unknown cause to DHSR.

NOTE: Incident reports are quality assurance documents. Do not file incident reports in the consumer’s service record. Confidentiality of consumer information is protected. Use the form according to confidentiality requirements in NC General Statutes and Administrative Code and the Code of Federal Regulations.

DMH/DD/SAS-Community Policy Management Section – Guide for Form QM02

Effective October, 2004 – Rev. 05/2010

Page 3 of 4

PROVIDER RESPONSE

North Carolina Department of Health & Human Services –Mental Health/Developmental Disabilities/Substance Abuse Services

DHHS Incident and Death Report

Describe the cause of the incident; why did the incident occur?

Describe how this type of incident may be prevented in the future and any corrective measures that have been or will be put in place as a result of the incident

Indicate authorities or persons notified of the incident (as applicable):

REPORTING INFORMATION

Agency / Person

Host LME

Home LME

Law enforcement

 

DSS County:

_________________

NC DMH/DD/SAS QM Team

NC DHSR Complaint Unit

NC DHSR Health Care Personnel Registry

Service Plan Team/Clinical Home Parent / Guardian

Other

Contact Name

Phone or FAX

()

()

()

()

()

()

()

()

()

()

Notification Date

Name/title of supervisor authorizing report and completing page 3. (Please print):

 

 

 

 

 

 

 

 

Phone (

)

 

 

Signature ________________________________________________________ Date

 

Time

 

 

 

a.m.

p.m

E-mail address:.

 

 

 

 

 

 

Direct questions to: ContactDMHQuality@ncmail.net Phone: (919) 733-0696

NOTE: Incident reports are quality assurance documents. Do not file incident reports in the consumer’s service record. Confidentiality of consumer information is protected. Use the form according to confidentiality requirements in NC General Statutes and Administrative Code and the Code of Federal Regulations.

DMH/DD/SAS-Community Policy Management Section – Guide for Form QM02

Effective October, 2004 – Rev. 05/2010

Page 4 of 4

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