Free Incident Reporting - Medicaid Waiver Programs - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-22541 (05/2009)

STATE OF WISCONSIN Completion of this form meets the requirements and conditions of the CMS-approved Medicaid Waiver programs

INCIDENT REPORT ­ MEDICAID WAIVER PROGRAMS
Instructions: This form may be completed in stages but must eventually be completed in its entirety. It is applicable to all children and adults receiving services through the BI, CLTS, CIP 1A/1B, COR and IRIS Medicaid Waiver programs. Additional information may be attached to supplement but not replace information provided on the report form. This form must be submitted via mail or FAX to the designated Contact for the specific Waiver program. Please consult the instructions in the Waiver manual for information about notification requirements and report deadlines. FAILURE TO REPORT INCIDENTS AS REQUIRED OR IN A TIMELY MANNER MAY RESULT IN A FULL OR PARTIAL DISALLOWANCE OF THE FUNDING CLAIMED FOR THE SUBJECT OF THE INCIDENT IF IT IS DETERMINED THAT THE PARTICIPANT'S SAFETY WAS NOT ASSURED BY THE WAIVER AGENCY. PARTICIPANT INFORMATION 1. Name - Last 2. Address ­ Street (Participant) 4. Birthdate 5. Gender Male Name - First City / State / Zip Code 7. Telephone Number Female SED BIW Other 10. County of Fiscal Responsibility MI

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8. Waiver Slot Number: (CLTS only)

6. Waiver Program CLTS DD PD CIP 1A CIP 1B COR IRIS 9. County of Physical Residence NOTIFICATION OF INCIDENT 11. Date Form Completed

12. Name - Primary Children's Services Specialist, Community Integration Specialist or person's chosen Independent Consultant. Critical 14. Date of initial notification

13. Type of Report (check all that apply below)

Original Update Correction Incident Review Completed and Closed 15. Original Reporter: Waiver Participant Guardian (Can check other choices if this choice is checked) Parent Other Family Member Staff in Provider Agency Staff in other Provider Agency Support and Service Coordinator/Broker Independent Consultant (IRIS only) State/County Licensing or Certification Staff Other Governmental (e.g., law enforcement) Anonymous Complaint Independent Provider/Non-Agency Staff Other Community Member Other: Specify: 16. Provide Brief Description of incident:

17. Describe action taken to date as a result of the incident to resolve incident and assure health and safety of participant:

PERSON COMPLETING FORM INFORMATION 18. Name - Last 19. Title 20. Name of Agency

Name - First

21. Telephone Number

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SUPPORT & SERVICE COORDINATOR / INDEPENDENT CONSULTANT INFORMATION (If different from above) 22. Name ­ Last Name - First 23 Telephone Number

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24. E-Mail address 25. Agency of Affiliation (If applicable): INCIDENT INFORMATION 26. Date of Event

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27. Location Event Occurred (Street, City, State, Zip Code)

28. Type of Setting where incident likely occurred: Residence Natural or adoptive home (with parents) Adult family home1-2 bed Person's own home Adult family home 3-4 bed Children's foster home/treatment foster home CBRF Other School Respite provider site Child care center Another person's residence Work site in community Waiver transportation provider; public Work site--congregate vocational provider Waiver transportation provider; agency or individual Day activity site Public transportation provider- not waiver funded Day treatment program Other - Specify: Community Setting--park, store, etc. 29. Was the perpetrator or alleged perpetrator involved or alleged to have been involved in the incident a paid service provider for subject of incident or was he/she not compensated for providing services and supports? Paid provider Unpaid 30. Name ­ Caregiver involved when incident occurred. 31. Name ­ Employer of the caregiver involved when incident occurred 32. Address of Provider Agency employing the caregiver (Street, City, State, Zip Code) OUTCOME AND CONCLUSION 33. Please provide a detailed description of the significant actions and events (e.g., staff terminated, arrested, etc.; person treated at ER) taken by all parties involved and their effects following the incident.

34. Please discuss changes to the waiver participant's situation or status as a result of the incident including revisions to the person's individualized service plan, provider/staff, living arrangement, school, work, guardian, etc., and how these changes assure the participant's safety and improve his/her quality of life.

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35. Type of change made or action taken by County/Waiver Agency or contractor as a result of Incident (check all that apply) Nothing changed l. Medically related consult a. b. m. Corrective action initiated Behavioral consult Terminate staff Staff providing training related to subject of incident c. n. d. o. Change in personnel working with the participant Refer to Licensing (Children's) Added staff coverage Refer to Licensing (Adult) e. p. f. q. Change agency that provides service Report to CPS Change to Individualized Service Plan Report to APS g. r. h. s. Added new service Report/Refer to caregivers Reduced service Refer to Disability Rights Wisconsin i. t. j. u. Terminated service Refer to District Attorney/law enforcement agency Increased amount and/or type of external monitoring of setting k. v. Other ­ Specify: EVENT / ALLEGATION CHECKLIST 36. Check applicable event type(s) / allegations below. Check "Alleged Only" if there is uncertainty about whether the event occurred. Alleged Alleged Event Type / Allegation Event Type / Allegation Only Only Neglect (Cont'd) Abuse Mental / emotional Medical / failure to seek Physical Nutrition Sexual Unsafe or unsanitary environmental Verbal conditions Self-neglect Misappropriation of the person's funds or property Unanticipated absence of provider Error in medication resulting in significant reaction requiring medical attention Death Accidental Anticipated Other Unanticipated Unexpected serious illness / injury / accident Related to psychotropic medication* Unexpected, untimely, urgent, emergency Related to restraint or seclusion* hospitalization Overdose of drugs or alcohol by participant Related to Suicide* Unexpected significant behavior, not NOTE: *Deaths related to above factors in a licensed addressed in a behavior support plan or certified facility must be reported to the Department Emergency / unplanned use of isolation/ Death Review Committee within 24 hours. seclusion / restraint Law Enforcement Related Misuse of restraint or other restrictive Commission of crime measure Victim of crime Suicide attempt Arrest or incarceration Significant damage to property Fire Unanticipated absence of participant Neglect Environmental Other--Please describe Fail to follow plan / poor care IF THE PARTICIPANT DIED, COMPLETE THE FOLLOWING: 37. Date of Death 38. Official cause of death as reported on the death certificate CONTACT / SUPPLEMENTAL REPORTING CHECKLIST 39. Check all persons / agencies contacted by county waiver agency A. Child Protective Services F. Parent / Guardian (Required) B1. Adult Protective Services G. Law Enforcement Agency B2. Wisconsin Incident Tracking Report Submitted H. Licensing Agency C. CSS / Children's Services Specialist I. Physician J. Provider Agency (Required for CLTS Waiver) D. Community Integration Specialist / CIS K. DHS Waiver Manager / Central Office (Required for CIP 1A / 1B) L. Caregiver Misconduct Statewide Complaint Hotline: 800-642-6552 E. IRIS Independent Consultant M. Other--Specify: I affirm that the information provided on this report accurately reflects the information obtained by the worker or agency in investigating the incident and that I have not withheld information concerning this incident.

SIGNATURE ­ Person Reporting

PRINT Name

Date Signed