Pa. Code tit. 55, pt. VIII, subpt. A, ch. 6000, subch. R, STATUTES, app K
FIRST SECTION (completed within 24 hours)
The First Section is to include the following information:
* DEMOGRAPHICS (pre-populated from HCSIS demographics)
Name of the individual involved/affected by the incident.
Individual's Base Service Unit (BSU) number.1
1 If the individual is not registered with a County MH/MR Program, the report is to list the county or state where the person is/was a resident.
County of Registration.
Gender.
Individual's date of birth.
MR Diagnosis.
Home address of the individual.
Living Arrangement of the individual.
Name and address of the reporting entity.
Location where the incident occurred.
Name of the point person.
* CATEGORIZATION
Date and time when the incident was recognized/discovered.
Primary and secondary category of the incident.
Determination if an investigation is required or desired.
Name of the Certified Investigator assigned, if the incident requires investigation.
* HEALTH AND SAFETY ASSURANCE
Description of the immediate and subsequent steps taken by the point person or other representatives of the provider to ensure the individual's health, safety and response to the incident, including date, time and by whom those steps were taken.
* INCIDENT DESCRIPTION
Narrative description of the incident completed by staff or other person(s) who were present when the incident occurred or who discovered that an incident had occurred.2
2 Providers may summarize the narrative description, but the written statements of the person(s) directly invilved are to be available for review, if needed.
FINAL SECTION (completed within 30 days)
The reporting entity will complete the Final Section of the incident report within 30 days from the date of the incident or of the date the provider learns of the incident (unless an extension has been made). The Final Section will retain all of the preceding information from the First Section and will add:
Name of the initial reporter.
Name of the individual's supports coordinator (pre-populated).
Whether CPR was administered.
Weather the Heimlich was administered.
If 911 was called, the time, date and person who called.
If the incident involves an illness or injury, the name of the practitioner/facility by whom the individual was treated initially, the date and time of the initial contact with a health-care/medical practitioner, the nature/content of the initial treatment/evaluation, and the nature of, date of, time of, and practitioner involved in any subsequent treatments, evaluations.
In the event of a death, indication if the individual was in hospice care, had a diagnosis of terminal illness, if a "Do Not Resuscitate" order was in effect, if the coroner was contacted, if an autopsy has been or will be performed.
Identification of all persons to whom the incident notification has been (or will be) submitted (i.e., family, law enforcement agency), the date the notification has been made, and the person who has/will notify the necessary parties.
Update of incident description, as needed.
Specific description of any injury received by the individual.
Present status of the individual in reference to the incident.
Identification of other persons who may have witnessed or been directly involved in the incident.
Specific signs and symptoms of any illness (acute or chronic) which may be contributory to the incident.
Any relevant background information on the individual, including medical history and diagnoses.
Date on which the investigation began, if required.
Summary of the investigator's findings and conclusions, if required.
If the incident involves an allegation of abuse or neglect, the conclusion reached on the basis of the investigation (i.e., the allegation is confirmed, not confirmed, inconclusive) and the status of the target.
Description of the steps taken by the provider in response to the conclusions reached as a result of the investigation.
If the incident involves an injury of unknown origin, confirmation of the cause (if one has been identified) and steps taken to prevent recurrence.
Description of any changes in the individual's plan of support necessitated by or in response to the incident.
Verification by the provider that all necessary corrective actions have been identified.
If any corrective action cannot/has not been completed by the time the Final Section is submitted, the expected date of completion must be provided along with the identity of the person responsible for carrying the extended action through to completion.
If the nature of the incident requires contact with local law enforcement, the name and department/office of the person(s) contacted, the date of the contact, the name of the person who initiated the contact, and a description of any steps taken by law enforcement officials.
If the individual has been hospitalized, the date of admission, name of the hospital, the admitting diagnosis(es), indication if the admission was from the emergency room, what occurred during the hospitalization, change in voluntary/involuntary status, the date of discharge, the discharge diagnosis(es), an indication that the Hospital Discharge Instructions were provided, what changed after discharge, current status and any plans for subsequent medical follow-up.
If the individual is deceased, the Final Section is to be supplemented by a hard copy of the following:3
3 Documents, which are not immediately available, must be forwarded to the appropriate parties (county and/or OMR Regional Office) as they become available. If, after attempting to acquire the document, it is determined to be unobtainable, the expecting party will be notified.
- Lifetime medical history.
- Copy of the Death Certificate.
- Autopsy Report, if one has been completed.
- Discharge Summary from the final hospitalization, if the individual died while hospitalized.
- Results of the most recent physical examination.
- Most recent Health and Medical assessments.
Name of the family member notified of the results of the investigation, if required.
The incident classification the provider believes is most appropriate.
The date and time the provider believes is most appropriate.
After final submission by the provider, the county and OMR will perform a management review and close the incident.
Pa. Code tit. 55, pt. VIII, subpt. A, ch. 6000, subch. R, STATUTES, app K
This appendix cited in 55 Pa. Code § 6000.961 (relating to standardized incident report).1 If the individual is not registered with a County MH/MR Program, the report is to list the county or state where the person is/was a resident.