Instructions for Form AGL-09 "Unusual Incident Report Form" - Pennsylvania

This document contains official instructions for Form AGL-09, Unusual Incident Report Form - a form released and collected by the Pennsylvania Department of Aging.

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Download Instructions for Form AGL-09 "Unusual Incident Report Form" - Pennsylvania

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UNUSUAL INCIDENT REPORT FORM (AGL-09) INSTRUCTIONS
REMINDER:
Regulation 11.16(c) requires that incidents involving abuse or suspected abuse, fire department or circumstances
requiring police action must be orally reported to the Department’s Division of Licensing within 24 hours after the incident
occurs. A written report, if submitted within 24 hours, fulfills the oral report requirement. All other incident reports shall be
submitted within 72 hours of the incident.
FACILITY INFORMATION:
Indicate the name and address of the facility, the name of the director, the facility’s license number and telephone
number, and the county in which the facility is located.
DATE/TIME OF INCIDENT:
Indicate the date and time the incident occurred.
TYPE OF INCIDENT:
Indicate the type of incident by placing a check in the box next to the appropriate category. Check all that apply.
CLIENT INFORMATION:
Indicate the name, sex, date of birth, and funding source of the client involved in the incident. If the client’s funding source
is not listed, check other and specify the source.
LOCATION OF INCIDENT:
Indicate where the incident occurred.
DESCRIPTION OF INCIDENT:
Provide a detailed description of the incident. Include the circumstances leading up to the incident, injuries (if any), and
other people who were involved in or witnessed the incident. Document information that is relevant to the incident. Attach
additional pages if necessary.
FOLLOW-UP ACTION TAKEN:
Indicate what action was immediately taken and what further action will be taken in response to the incident or following
the conclusion of the incident investigation. Attach supporting documentation, including but limited to: a description of
changes to the client care plan, progress or treatment notes, revised policies/procedures, staff/client in-service training,
staff/client counseling, and staff disciplinary measures. Add statements regarding the measures taken to reduce the risk
of repeat [preventable] incidents, if applicable. Include any referrals made.
NOTIFICATION:
Indicate who was notified, by what means, and the date and time of the notification.
ACT 13 NOTIFICATION:
For cases of abuse or suspected abuse that occur at the center or involve center staff, indicate who was notified, by what
means, and the date and time of the notification. The center must immediately notify the Area Agency on Aging. In cases
of serious physical injury, serious bodily injury, sexual abuse or suspicious death, the center must also orally notify local
law enforcement and the Department of Aging.
CONTACT INFORMATION:
Indicate the name and title of the person who completed the report. The person who completed the report must sign and
record the date and time of the report (electronic signature is acceptable). Indicate the telephone number of the person
who will serve as the contact person. If the contact person is not the person who completed the form, provide the contact
person’s name in the telephone number field.
REPORTING INSTRUCTIONS:
Type the report. Do not abbreviate words or use acronyms. Send report to: ADLC-UIReport@pa.gov.
IMPORTANT – HCSIS Reports are no longer accepted.
Commonwealth of Pennsylvania
AGL-09 Unusual Incident Report Instructions
Department of Aging
11/12
UNUSUAL INCIDENT REPORT FORM (AGL-09) INSTRUCTIONS
REMINDER:
Regulation 11.16(c) requires that incidents involving abuse or suspected abuse, fire department or circumstances
requiring police action must be orally reported to the Department’s Division of Licensing within 24 hours after the incident
occurs. A written report, if submitted within 24 hours, fulfills the oral report requirement. All other incident reports shall be
submitted within 72 hours of the incident.
FACILITY INFORMATION:
Indicate the name and address of the facility, the name of the director, the facility’s license number and telephone
number, and the county in which the facility is located.
DATE/TIME OF INCIDENT:
Indicate the date and time the incident occurred.
TYPE OF INCIDENT:
Indicate the type of incident by placing a check in the box next to the appropriate category. Check all that apply.
CLIENT INFORMATION:
Indicate the name, sex, date of birth, and funding source of the client involved in the incident. If the client’s funding source
is not listed, check other and specify the source.
LOCATION OF INCIDENT:
Indicate where the incident occurred.
DESCRIPTION OF INCIDENT:
Provide a detailed description of the incident. Include the circumstances leading up to the incident, injuries (if any), and
other people who were involved in or witnessed the incident. Document information that is relevant to the incident. Attach
additional pages if necessary.
FOLLOW-UP ACTION TAKEN:
Indicate what action was immediately taken and what further action will be taken in response to the incident or following
the conclusion of the incident investigation. Attach supporting documentation, including but limited to: a description of
changes to the client care plan, progress or treatment notes, revised policies/procedures, staff/client in-service training,
staff/client counseling, and staff disciplinary measures. Add statements regarding the measures taken to reduce the risk
of repeat [preventable] incidents, if applicable. Include any referrals made.
NOTIFICATION:
Indicate who was notified, by what means, and the date and time of the notification.
ACT 13 NOTIFICATION:
For cases of abuse or suspected abuse that occur at the center or involve center staff, indicate who was notified, by what
means, and the date and time of the notification. The center must immediately notify the Area Agency on Aging. In cases
of serious physical injury, serious bodily injury, sexual abuse or suspicious death, the center must also orally notify local
law enforcement and the Department of Aging.
CONTACT INFORMATION:
Indicate the name and title of the person who completed the report. The person who completed the report must sign and
record the date and time of the report (electronic signature is acceptable). Indicate the telephone number of the person
who will serve as the contact person. If the contact person is not the person who completed the form, provide the contact
person’s name in the telephone number field.
REPORTING INSTRUCTIONS:
Type the report. Do not abbreviate words or use acronyms. Send report to: ADLC-UIReport@pa.gov.
IMPORTANT – HCSIS Reports are no longer accepted.
Commonwealth of Pennsylvania
AGL-09 Unusual Incident Report Instructions
Department of Aging
11/12