Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart A - Statements of Policy › Chapter 6000 - STATEMENTS OF POLICY › Subchapter R - PROCEDURES FOR SURROGATE HEALTH CARE DECISION MAKING › STATUTES › Appendix K - STANDARDIZED INCIDENT REPORT

Current through Register Vol. 54, No. 28, July 13, 2024
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.
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.