Form 470-4698 Iowa Medicaid Critical Incident Report - Iowa

Form 470-4698 or the "Iowa Medicaid Critical Incident Report" is a form issued by the Iowa Department of Human Services.

Download a fillable PDF version of the Form 470-4698 down below or find it on the Iowa Department of Human Services Forms website.

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Iowa Department of Human Services
Iowa Medicaid Critical Incident Report
Date Received
Incident ID
Staff Reviewer
Instructions: Submit all pages of this form with as much information as possible within the required
reporting timeframes.
Incident Status:
Managed Care Organization:
Initial (pending further investigation)
Amerigroup Iowa
Completed (investigation completed)
UnitedHealthcare Community Plan
Additional information added
Non-MCO
National Provider Identifier
Phone Number
Provider or Agency Name
Provider Address
City
State
Zip Code
Reporter’s First Name
Last Name
Title
Email
Phone Number
Point of contact to discuss incident if different from reporter:
First Name
Last Name
Phone Number
Medicaid State Number
First Name
Last Name
Address
City
State
Zip Code
Date of Birth
Age
Member’s gender:
Male
Female
AIDS/HIV
Habilitation
MFP
Brain Injury
Health and Disability
Other (non-waiver):
Describe:
Children’s Mental Health
Intellectual Disability
Elderly
Physical Disability
First Name
Last Name
Address
City
State
Zip Code
Email
Phone Number
Case manager contacted member within 24 hours of discovering incident?
Yes
No
Date CM Contacted Member
Time CM Contacted Member
470-4698 (Rev. 1/18)
Page 1 of 6
Iowa Department of Human Services
Iowa Medicaid Critical Incident Report
Date Received
Incident ID
Staff Reviewer
Instructions: Submit all pages of this form with as much information as possible within the required
reporting timeframes.
Incident Status:
Managed Care Organization:
Initial (pending further investigation)
Amerigroup Iowa
Completed (investigation completed)
UnitedHealthcare Community Plan
Additional information added
Non-MCO
National Provider Identifier
Phone Number
Provider or Agency Name
Provider Address
City
State
Zip Code
Reporter’s First Name
Last Name
Title
Email
Phone Number
Point of contact to discuss incident if different from reporter:
First Name
Last Name
Phone Number
Medicaid State Number
First Name
Last Name
Address
City
State
Zip Code
Date of Birth
Age
Member’s gender:
Male
Female
AIDS/HIV
Habilitation
MFP
Brain Injury
Health and Disability
Other (non-waiver):
Describe:
Children’s Mental Health
Intellectual Disability
Elderly
Physical Disability
First Name
Last Name
Address
City
State
Zip Code
Email
Phone Number
Case manager contacted member within 24 hours of discovering incident?
Yes
No
Date CM Contacted Member
Time CM Contacted Member
470-4698 (Rev. 1/18)
Page 1 of 6
Date Incident Occurred (required)
Time of Incident
a.m.
p.m.
Unknown
Date Incident Discovered (required)
Was the incident witnessed?
Yes
No
Person to learn of incident:
First Name
Last Name
Title
Select Location Type (If other, specify.)
Member’s home
Community
Other location
Living alone
Work
State facility
Living with relatives
School
Correctional facility or jail
Living with unrelated person
Vehicle
Nursing facility
RCF
Day program
Hospital or clinic
Assisted living
Other:
PMIC
Other:
Other:
Name of Location or Facility
Location or Facility Address
City
State
Zip Code
People Present During Incident (Provide name of person, initials if a member, and the person’s
relationship to the member. If other, specify.)
1.
Another member
Staff
Family
Roommate
Other:
2.
Another member
Staff
Family
Roommate
Other:
3.
Another member
Staff
Family
Roommate
Other:
4.
Another member
Staff
Family
Roommate
Other:
5.
Another member
Staff
Family
Roommate
Other:
Were services being provided?
Yes
No
Service Name
Date Informed
Case manager informed?
Yes
No
N/A
Date Informed
Guardian informed?
Yes
No
N/A
Date of Report
DHS report made?
Yes
No
N/A
Report Number
DHS report accepted?
Yes
No
Department of Inspections and Appeals (DIA)?
Date of Report
Yes
No
N/A
Date Contacted
Law enforcement?
Yes
No
N/A
Officer Name and Contact Information
Other Entity Contacted (Specify)
470-4698 (Rev. 1/18)
Page 2 of 6
Description (Include who, what, when, where, and how in a clear concise manner noting the
circumstances of the incident.)
Was the incident preventable?
Yes
No
Root Cause (Describe what lead to or contributed to the incident.)
Immediate Resolution (Include action taken to secure the member’s safety and proposed
prevention plan to address.)
Circumstances (Select one):
Physical injury to member
Physical injury by member
Physical Injury (Injury requiring physician’s treatment or admission to a hospital.)
Burn
Laceration
Poisoning or toxin ingestion
Dislocation
Puncture wound
Other:
Concussion
Fracture or break
Human or animal bite
Loss of consciousness
Injury Is Due To (Check all that apply.)
Mechanical restraint
Aggressive behavior
Vehicular accident
Removal of mobility aids
Accidental fall
Assault
Personal harm
Aspiration or choking
Other:
Medication Error (Medical intervention sought or pattern of medication errors identified.
Check all that apply.)
By staff
Wrong dosage
Unauthorized administration
By member
Wrong medication
Overdose
Missed dose
Other:
Wrong time
Root Cause (Check all that apply.)
Staff distracted
Not verifying correct
Unknown
member
Medication Error Led To (Check all that apply.)
Physical injury
Emergency mental health
Abuse report
Death
Law enforcement
Death Apparent cause of death:
Accident
Natural causes
Suicide
Homicide
Unknown
Preventable?
Yes
No
Autopsy performed?
Yes
No
Autopsy requested?
Yes
No
Was there a DNR order?
Yes
No
Hospice involved?
Yes
No
Location Death Occurred
Location Address
City
State
Zip Code
470-4698 (Rev. 1/18)
Page 3 of 6
Emergency Mental Health (Check all that apply.)
Suicidal?
Yes
No
Self-injurious?
Yes
No
Aggressive to others?
Yes
No
Member needed to be
Yes
No
admitted for treatment?
Law Enforcement Reason involved:
Medical
Criminal
Location unknown/elopement
Mental health
Welfare check
Other (describe):
Behavioral
Arrested?
Victim
Yes
No
Charged?
Perpetrator
Yes
No
Abuse Report or Restriction
Physical injury
Victim
Sexual abuse
Perpetrator
Exploitation
Denial of critical care
Self-denial of critical care
Mental injury
Location Unknown/Elopement (Location unknown by provider responsible for protective
oversight.)
Approximate length of time location unknown:
Incident-Specific Resolutions
This section includes multiple types of resolutions possible for reported incidents. Check all that
apply. Describe the agency course of action, proposed plans, self-corrective actions, measures
needed to prevent or diminish the probability for future occurrences or other information needed for
each checked resolution.
Staff Review and Updates (Complete this section if staff issues will be addressed by the
agency or facility. Describe any changes in staffing patterns.)
Initiated
Completed
Describe:
Member Review (Complete this section if the member’s plan, health, or care needs will be
reviewed or revised.)
Initiated
Completed
Member care and treatment plan revised?
Yes
No
Describe:
Equipment and Supplies Review and Updates (Complete this section if necessary
equipment or supplies need to be purchased, repaired, or assessed.)
Initiated
Completed
Describe:
470-4698 (Rev. 1/18)
Page 4 of 6
Environment Review and Updates (Complete this section if the member’s environment will
be evaluated, accommodated, or modified for safety or accessibility needs.)
Initiated
Completed
Describe:
Policy and Procedure Review and Updates (A review or adjustment of formal written
policies, procedures, and guidelines implemented by the agency or facility.)
Initiated
Completed
Describe:
Agency Wide Planning (Systemic resolution to include, but not limited to, training or
retraining, self-CAP, communication and awareness regarding updates, employee screening,
etc.)
Initiated
Completed
Self-corrective action initiated?
Yes
No
Describe:
No Resolution Required (Indicate how incident was isolated.)
Describe:
Additional Follow-up and Notes (Place additional detail regarding incident or resolution as
discovered.)
Verify Validations
470-4698 (Rev. 1/18)
Page 5 of 6

Download Form 470-4698 Iowa Medicaid Critical Incident Report - Iowa

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