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Nursing Home Incident Report Form: What You Should Know

A “Incident” report includes information of the incident including: (a) The date, time, and location of the incident; (a) A description of how the incident originated; (b) The name of the individuals involved in the incident; and (c) The cause of the incident. HRS §9.6.40. incident Report Form Data Form. (d) If a Care Coordinator participated in the incident, the report will include the name of that Care Coordinator and any other names of individuals participating in the incident, when appropriate. HRS §9.6.45. incident Report Form Data Form. (e) If a Care Coordinator is participating in an incident, the reporting party is responsible for the information contained in the report. A Care Coordinator can edit the incident report based upon the nature of the incident, for which a Care Coordinator determines that there is information that is necessary and significant to be included. A Care Coordinator may or may not have participated in the report. A Care Coordinator who participated should have written permission from an appropriate supervisory person to edit the report. A Care Coordinator that is not participating should not have that information, except the name of an individual involved in the situation. HRS §§9.6.40 and 9.6.45. ‬Incident Report Form Data Form. (f) If multiple individuals are participating in an incident, the care staffer who is designated as the Incident Coordinator should be contacted to obtain information and provide consent and authorization for the incident report. For cases of care coordination, care coordination entities who are not involved in an incident, but who are involved in patient care and/or patient safety shall be contacted to obtain consent and authorization to review the incident report. HRS §9.6.50. Health Home Incident Report Format The Care Coordinators who oversee the day-to-day actions of care coordinators and staff members in a Health Home are responsible for completing and submitting an incident report on a weekly basis using the incident reporting form. When requesting the incident report from HRS §9.6.40, please provide the facility name or address/location/city/state where the event occurred along with the specific time(s) of the incident. Useful Information about the HCS Incident Reporting System Note: The information contained in this section of the webpage may be out of date or incorrect.

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