Pa Personal Care Home Form PDF Details

In personal care homes across Pennsylvania, the safety and well-being of residents are of paramount importance. Recognizing this, the state has implemented a detailed reporting system for incidents that may occur within these facilities. The Pennsylvania Personal Care Home form serves as a critical tool in this effort, outlining a structured process for documenting and addressing various incidents that impact resident safety. This comprehensive form covers a wide range of reportable events, from the death of a resident, serious injuries, violations of rights, to outbreaks of communicable diseases, among others. Facilities are required to provide detailed information about each incident, including the nature of the event, the circumstances leading up to it, and any follow-up actions taken in response. In addition, the form mandates timely notifications to relevant authorities and individuals, ensuring a coordinated and prompt response to protect the welfare of residents. By standardizing the reporting process, the form underscores Pennsylvania’s commitment to maintaining high standards of care and accountability in personal care homes.

QuestionAnswer
Form NamePa Personal Care Home Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespch forms, pa dhs incident report form, personal care reportable incident form, personal care homes form

Form Preview Example

ADULT RESIDENTIAL LICENSING – PERSONAL CARE HOMES REPORTABLE INCIDENT – 55 Pa.Code § 2600.16

TYPE OF REPORT

Initial

Final (no prior report submitted)

Final (prior report was submitted)

Both Initial and Final

FACILITY INFORMATION

NAME OF LEGAL ENTITY:

NAME OF ADMINISTRATOR

TELEPHONE:

ADDRESS OF LEGAL ENTITY:

NAME OF PERSONAL CARE HOME (if different from Legal Entity):

LICENSE #

 

 

ADDRESS OF PERSONAL CARE HOME (if different from Legal Entity):

 

COUNTY NAME/#:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE/TIME OF INCIDENT

 

 

 

 

 

 

 

 

Date:

Time:

AM/PM

 

 

 

 

TYPE OF INCIDENT: Check all that apply:

Death of a resident.

Physical act by a resident to commit suicide.

Serious bodily injury or trauma requiring treatment at a hospital or medical facility.

Violation of a resident's rights.

Unexplained absence of a resident for 24 hours or more, or when the support plan so provides, a period of less than 24 hours, or an absence of a resident from the secured dementia care unit.

Misuse of a resident's funds by the home's staff persons or legal entity.

Outbreak of a serious communicable disease.

Food poisoning of residents.

Physical or sexual assault by or against a resident.

Fire or structural damage to the home.

Incident requiring the services of an emergency management agency, fire department or law enforcement agency. Complaint of resident abuse, suspected resident abuse or referral of a complaint of resident abuse to a local authority.

Prescription medication error.

Emergency in which the procedures under 2600.107 (relating to emergency preparedness) are implemented.

Unscheduled closure of the home or the relocation of the residents.

Bankruptcy filed by the legal entity.

Criminal conviction against the legal entity, administrator or staff that are subsequent to the reporting on the criminal history checks under 2600.51 (relating to criminal history checks).

Termination notice from a utility.

Violation of applicable health and safety laws.

DESCRIPTION OF INCIDENT: Provide at least the following information: Where did the incident happen? What were the circumstances leading up to the incident? Who were the other people involved in incident and how they can be contacted?

(Attach additional pages if necessary).

RESIDENT INFORMATION: Complete for any incident relating to a specific resident(s).

Name(s)of Resident(s)

Last

First

 

MI

 

 

Sex

 

 

Date of birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Commonwealth of Pennsylvania

1

DPW – ARL

Department of Public Welfare

 

12-05

NAME OF PERSONAL CARE HOME:

FOLLOW-UP ACTION TAKEN: What action, if any, was initiated or is planned in response to the incident? What, if any, further action will be taken? Include any referrals made. (Attach additional pages if necessary).

 

NOTIFICATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Regional Adult Residential Licensing Office

 

Yes

 

 

 

Telephone

 

Date

 

 

 

 

 

 

 

 

 

 

No

 

 

 

Written

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Resident

 

 

 

 

 

 

 

Yes

 

 

 

Telephone

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

Written

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Resident's Designated Person

 

 

 

 

 

Yes

 

 

 

Telephone

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

Written

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Residents

 

 

 

 

 

 

 

Yes

 

 

 

Telephone

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

Written

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Others

 

 

 

 

 

 

 

Yes

 

 

 

Telephone

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

Written

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTACT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of person completing report:

 

 

 

 

 

 

 

 

Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date/time this report was completed:

Date:

Time:

 

 

 

AM/PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Person Name:

 

 

 

 

 

Contact Person Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUMMARY OF REGULATORY REPORTING REQUIREMENTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALL INCIDENTS

24 hours - Written report to Department's Regional Adult Residential Licensing Office

 

 

CERTAIN INCIDENTS

24 hours – Phone call to Regional Adult Residential Licensing Office

 

 

 

 

 

1.

Unexpected death

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Unexplained absence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Fire/Structure damage making home uninhabitable

 

 

 

 

 

4.

Emergency under 2600.107 5.

Unscheduled closure of home

 

 

 

 

 

6. Termination of heat in winter

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. Termination of water or electricity

 

 

 

 

 

 

 

 

 

 

ALL INCIDENTS –

IMMEDIATELY FOLLOWING THE CONCLUSION OF THE INVESTIGATION –

 

 

 

 

 

Final written report to the Regional Adult Residential Licensing Office

 

 

 

 

VALID INCIDENTS –

IMMEDIATE - Written or oral report to effected residents or designated persons

 

FOR DEPARTMENT OF PUBLIC WELFARE USE ONLY:

REGIONAL ASSIGMENT (if any):

REGIONAL LICENSING ADMINISTRATOR DATE/INITIAL:

Commonwealth of Pennsylvania

2

DPW – ARL

12-05

Department of Public Welfare

 

 

 

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This form needs some specific details; to ensure accuracy and reliability, be sure to adhere to the recommendations further down:

1. First, when filling in the personal care reportable incident form, beging with the section that has the following blanks:

pa reportable incident form writing process shown (portion 1)

2. Once the previous segment is completed, you're ready insert the needed specifics in Physical or sexual assault by or, Fire or structural damage to the, Incident requiring the services of, Complaint of resident abuse, Prescription medication error, Emergency in which the procedures, Unscheduled closure of the home or, Criminal conviction against the, Termination notice from a utility, Violation of applicable health and, DESCRIPTION OF INCIDENT Provide at, and RESIDENT INFORMATION Complete for allowing you to go to the 3rd stage.

The way to fill in pa reportable incident form portion 2

3. Completing Namesof Residents Last, First, Sex, Date of birth, Commonwealth of Pennsylvania, and DPW ARL is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Completing part 3 in pa reportable incident form

4. Completing FOLLOWUP ACTION TAKEN What action, NOTIFICATION, Regional Adult Residential, Resident, Residents Designated Person, Other Residents, Yes, Yes, Yes, Yes, Telephone, Date, Written, Telephone, and Written is essential in the fourth form section - don't forget to invest some time and take a close look at each and every empty field!

Filling in segment 4 of pa reportable incident form

5. To conclude your form, this final segment has a couple of extra blanks. Typing in Others, Yes, Written, Time, Telephone, Date, Written, Time, CONTACT INFORMATION, Name of person completing report, Title, Datetime this report was completed, Date, Time, and AMPM should conclude everything and you can be done very fast!

pa reportable incident form completion process described (stage 5)

As to Date and Others, ensure that you don't make any mistakes in this current part. These are thought to be the key ones in this page.

Step 3: Prior to moving on, you should make sure that form fields are filled out properly. Once you are satisfied with it, click on “Done." Get hold of the personal care reportable incident form as soon as you join for a free trial. Instantly use the pdf file within your FormsPal account, along with any modifications and changes automatically synced! Whenever you work with FormsPal, you can complete forms without the need to worry about personal information breaches or records being shared. Our protected platform helps to ensure that your private details are kept safely.

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