Ensuring the welfare and safety of children within the healthcare system requires diligence and continuous oversight. The OCFS-8015B form serves as a critical tool within this framework, particularly within New York State's Office of Children and Family Services for the Bridges to Health (B2H) Home & Community Based Services Medicaid Waiver Program. This document is designed for completion by Health Care Integration Agencies (HCIA) and must be submitted biannually to the Bureau of Waiver Management. The form is structured to provide a comprehensive overview of serious incidents that have occurred, offering insights into trends of serious reportable incidents, and evaluating the responses and recommendations made by both the review committee and any involved Waiver Service Provider. It seeks detailed assessments regarding whether actions taken were thorough, sufficient, and in alignment with best clinical practices, and importantly, whether there is a need for changes to prevent future occurrences. The form not only facilitates a methodical review of incidents but also encourages accountability and continuous improvement in care standards, making it an indispensable instrument in safeguarding the well-being of children receiving home and community-based services.
| Question | Answer |
|---|---|
| Form Name | Form Ocfs 8015B |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | b2h serious reportable incident form, reoccurrence, OCFS-8021, Wavier |
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NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES
SERIOUS INCIDENT REVIEW COMMITTEE QUARTERLY REPORT
BRIDGES TO HEALTH (B2H) HOME & COMMUNITY BASED SERVICES MEDICAID WAIVER PROGRAM
INSTRUCTION: To be completed by the Health Care Integration Agency (HCIA) and submitted to the Bureau of Wavier Management two weeks following the end of each quarter. Attach additional sheets if necessary.
HEALTH CARE INTEGRATION AGENCY REPRESENTATIVE:
HEALTH CARE INTEGRATION AGENCY SIGNATURE:
X
DATE:
HEALTH CARE INTEGRATION NAME:
HEALTH CARE INTEGRATION ADDRESS:
CITY:
STATE:
ZIP CODE:
Quarterly report dates
(Check one only):
1st Quarter
2nd Quarter April – June
3rd Quarter
July – September
4th Quarter
October- December
SECTION 1
1.QUARTERLY SUMMARY: Record the number of serious incidents under review during this quarter.
2.Identify any trends in Serious Reportable Incidents:
SECTION 2
Complete the following for EACH Closed Serious Reportable Incidents during the quarter.
1.Report # (from Serious Reportable Incident form,
2.Was the Committee’s response and that of any involved Waiver Service Provider
thorough and complete? |
Yes |
No |
Comments:
3. |
Was the final recommendation and action taken sufficient? |
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Yes |
No |
N/A |
Comments: |
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4. |
Was the final recommendation in line with best clinical practice? |
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Yes |
No |
N/A |
Comments: |
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5. |
Is there a need for recommendations for changes that may prevent or minimize |
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reoccurrence of the incident? |
Yes |
No |
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Comments: |
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6. |
Were there any identified preventive or disciplinary actions as a result of this Serious |
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Reportable Incident? |
Yes |
No |
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Comments:
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Complete the following for EACH Closed Serious Reportable Incidents during the quarter. (use for each additional incident).
SECTION 2 Continued
1.Report # (from Serious Reportable Incident FORM
2.Was the Committee’s response and that of any involved Waiver Service Provider thorough and complete?
Comments:
3. Was the final recommendation and action taken sufficient?
Comments:
4. Was the final recommendation in line with best clinical practice?
Comments:
5.Is there a need for recommendations for changes that may prevent or minimize reoccurrence of the incident?
Yes No
Yes |
No |
N/A |
Yes |
No |
N/A |
Yes No
Comments:
6.Were there any identified preventive or disciplinary actions as a result of this Serious Reportable Incident?
Yes
No
Comments:
Original – OCFS Bureau of Waiver Management; Copy – Health Care Integration Agency, Local Department of Social Services
and Division of Juvenile Justice and Opportunities for Youth (DJJOY), OCFS Quality Management Specialist