Free 52384.pdf - Indiana


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Date: September 23, 2005
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State: Indiana
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REPORT OF SERIOUS OCCURRENCE
State Form 52384 (9-05)

Indiana Protection and Advocacy Services (IPAS) 4701 N. Keystone Ave., Suite 222 Indianapolis, IN 46205 Fax (317) 722-5564 Voice 800-622-4845

INSTRUCTIONS: 1. Psychiatric Residential Treatment Facilities (PRTF) as defined in 42 CFR § 483.352 MUST report any serious occurrence involving a resident to both the State Medicaid agency (Office of Medicaid Policy and Planning) and the Indiana Protection and Advocacy Services (IPAS) by no later than the close of business of the next business day after a serious occurrence. 2. The report must be completed and faxed to (317) 722-5564, IPAS, by no later than 4:30 p.m. of the next business day after a serious occurrence. The sending facility needs to then initiate a voice confirmation of the successful receipt of the fax by IPAS by calling 1-800-622-4845. 3. The completed report must also be faxed to (317) 232-7382, Attention: Director of Program Operations-Acute Care, Office of Medicaid Policy and Planning, by no later than 4:30 p.m. of the next business day after a serious occurrence. 4. The DEATH of a resident MUST be reported to Centers for Medicare and Medicaid Services (CMS) by no later than 6:00 p.m. Central Time on the next business day after the resident's death. Fax: (312) 886-2303 Voice: (312) 353-0519 Requirements for documenting reports of serious occurrences are set out in 42 CFR § 483.374.

FACILITY INFORMATION
Name of facility Telephone number (area code-XXX-XXX) Address (number and street, city, state, zip code)

Name of individual completing this report

Position/Title

Telephone number (area code-XXX-XXX)

Extension

Today's date (month, day, year)

RESIDENT INFORMATION
Name of resident (First, M.I., Last) Date of birth (month, day, year)

Admission date (month, day, year)

Gender of resident

Male

Female

GUARDIAN OF RESIDENT INFORMATION
Name of guardian (First, Last) Relationship of guardian to resident

Address (number and street, city, state, ZIP code)

Telephone number (area code-XXX-XXX)

Enter the date and time the guardian was notified of serious occurrence. Date (month, day, year) Time Name and title of staff that contacted guardian

AM PM
Was Child Protective Services (CPS) notified of the SERIOUS OCCURRENCE? Was Adult Protective Services (APS) notified of the SERIOUS OCCURRENCE?

Yes Yes

No No

SERIOUS OCCURRENCE INFORMATION
Date of serious occurrence (month, day, year) Time Location of serious occurrence (ward/unit/area)

AM PM
Type of serious occurrence

Death

Suicide Attempt

Serious Injury

Pursuant to 42 CFR 483.374(c), you must report a resident's DEATH, by no later than close of business on the next business day after the resident's death, directly to: Health Insurance Specialist, Centers for Medicare and Medicaid Services (CMS), Chicago, Illinois Telephone (voice): (312) 353-0519 Fax: (312) 886-2303 Reports are accepted between 6:30 a.m. and 6:00 p.m. Central Time (Chicago observes Daylight Saving Time April through October)
Enter the date and time the resident's death was reported directly to CMS: Date (month, day, year) Time

AM PM

Is the report to CMS documented in the resident's record as required? Yes No Yes No

Did the SERIOUS OCCURRENCE occur during the use of either restraint or seclusion?

Provide a description of the occurrence (attach additional sheets if needed)

Number of additional sheets added (if none then write None)
State Form 52384 (9-05) Page 2 of 2