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Incident Reports A&B

When completing Incident Reports A&B it is important that you provide all information necessary, in the proper format so that the Critical Incident Supervisor (CIS) can complete EIM reports appropriately.

This guide specifically focuses on how to fill out Incident Reports. For training on Critical Incident Reporting, refer to the Critical Incident Reporting guide in the Knowledge Base

Incident Reports are filled out in Docusign, which you can receive when you request them from your supervisor when you need them!


Incident Report Part A

Incident Report Part A must be done within 24 hours of notification about a Critical Incident.

  1. General/Demographic information about the participant:
  • MCO: Select the MCO the participant is enrolled with
    • All of our participants are enrolled with PA HEALTH & WELLNESS
  • Discovery Date: The date the SC was notified/discovered the incident.
  • Discovery Time: The time when the SC was notified/discovered the incident.
  • Last Name, First Name: The name of the participant
  • DOB: Participant’s Date of Birth
  • MCI#: The Recipient ID# of the participant
  1. Basic information about the incident
  • Primary Category: The primary reason for reporting the incident. If the event meets multiple criteria, refer to the Incident Reporting Training guide for the hierarchy of categories.
  • Date Incident Occurred: The actual date(s) when the reported incident occurred.
  • Was this incident referred to Adult Protective Services: Did you, the participant, or another person involved refer to APS or OPAS?
    • Date/Time: Date and time APS referral was made
    • Rep Name: Name of the representative that the referral was made to
    • Phone: Phone number of the APS Representative.

Note: The text box for “Date Incident Occurred” may cut off the text to the other questions, but you still have to answer them.

Example of filled out second portion of Incident Report Part A
  1. Details about the Incident.
  • Initial Reporter Type: Select the type of person that reported the incident to the SC.
  • Last Name, First Name: The name of the individual who reported the incident to the SC.
    • Note, if the individual was the participant, then put their name here again.
  • Phone number: The phone number of the individual who reported the incident to the SC.
  • Incident Description: A detailed description of the event that took place.
  • Location of Incident: Where the participant was when the incident took place. Put in specific addresses if appropriate.
  • Initial Action Taken: The initial action that the Service Coordinator took when notified of the incident.
Example of filled out Incident Report Part A

4. Signature

  • Sign and date the incident Report

Incident Report Part B

Incident Report Part B must be done as soon as you know all the details about the Incident and within 20 days of notification about a Critical Incident.

  1. General/Demographic information about the participant:
  • MCO: Select the MCO the participant is enrolled with
    • All of our participants are enrolled with PA HEALTH & WELLNESS
  • Discovery Date: The date the SC was notified/discovered the incident.
    • This should be the same date stated on Incident Report Part A
  • Discovery Time: The time when the SC was notified/discovered the incident.
    • This should be the same time stated on Incident Report Part A
  • Last Name, First Name: The name of the participant
  • DOB: Participant’s Date of Birth

2. Details about the Incident

  • Investigation: The Start and End Date of the Investigation/Incident
    • Start Date: The date SC was notified of the Incident
    • End Date: The date the SC is completing Incident Report Part B
  • Description of Incident: A detailed description of the event that took place.
  • Initial Action Taken: The initial action that the Service Coordinator took when notified of the incident.

Note: Description of Incident and Initial Action Taken can/may be the same as Incident Report Part A, unless there are corrections that need to be made.

Example of filled out Incident Report Part B

3. Resolution

  • Incident Witness: This is the “Initial Reporter” mentioned in Part A
    • Last Name, First Name: Name of the individual who reported the incident to the SC.
    • Phone Number: The phone number of the individual who reported the incident to the SC.
  • Investigative Action Taken: How SC investigated the incident, or obtained information regarding the incident.
  • Resolution: Details about how the incident was resolved, including medical treatment performed, new or changes to medications, new or changes to services, risk mitigation efforts and RCA information (if applicable).

It is important the Resolution be detailed and include all of the following information if applicable:

  • Participant Name:
  • Name of the Hospital:
  • Discharge Date:
  • Discharge Diagnosis:
  • Changes to Current Medications or New Medications
    • Dosage
    • Route
    • Frequency
  • Were treatments or Medical Equipment initiated by the Hospital?
  • Was the ptp discharged to a SNF?
    • How long/duration:
    • Facility Name:
    • Date and Discharge of Transfer:
  • Follow-up scheduled with PCP or Specialist/Date:
  • Is there need for Skilled Services (Nursing, PT/OT) in home?
  • Were there any changes to PAS or was the Service Plan adjusted or changed in amount, frequency, or Duration of existing supports and services.
  • Are the ptp’s needs being met?
    • Concerns for the ptp’s safety?
    • Is the ptp at risk?
    • What has been put in place in the Plan of Care to address the concern?
  • Measures taken to prevent or mitigate recurrence of incident:
  • Was the participant provided education/steps to prevent further incidents?
Example of filled out Incident Report Part B

4. Signature

  • Sign and date the incident Report
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