"Older Adult Daily Living Center Unusual Incident Report" - Pennsylvania

Older Adult Daily Living Center Unusual Incident Report is a legal document that was released by the Pennsylvania Department of Aging - a government authority operating within Pennsylvania.

Form Details:

  • Released on January 1, 2015;
  • The latest edition currently provided by the Pennsylvania Department of Aging;
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Download "Older Adult Daily Living Center Unusual Incident Report" - Pennsylvania

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OLDER ADULT DAILY LIVING CENTER
Unusual Incident Report
6 Pa. Code § 11.16
FACILITY INFORMATION
Name of Facility:
License Number:
Address of Facility:
County:
Name of Director:
Telephone Number:
DATE AND TIME OF INCIDENT
Date:
Time:
AM
PM
TYPE OF INCIDENT: (Check all that apply)
Criminal conviction against the legal entity, owner, operator or employee as described in 6 Pa. Code § 11.281
Injury, trauma or illness of a client requiring treatment at a medical facility
Violation or suspected violation of a client’s rights
A client who is missing and presumed to be at risk (all elopements are considered reportable)
Abuse, neglect or exploitation or suspected abuse, neglect or exploitation of a client
Misuse or suspected misuse of a client’s funds or property
Outbreak of a communicable disease as defined in 28 Pa. Code § 27.2
An incident involving the fire department or circumstances requiring police action
A condition, except for snow or ice, that results in closure of the facility for more than one scheduled day of operation
Client death, that occurs at the center per 6 Pa. Code § 11.17
CLIENT INFORMATION
Name of Client: (Last, First)
Sex
Date of Birth
M:
F:
Funding Source
Aging Waiver
COMMCARE
Independence
OBRA
Options
Private
Other (Specify) ______________________
LOCATION OF INCIDENT: (Bathroom, Program Area, Center Grounds, etc)
DESCRIPTION OF INCIDENT: Provide a detailed description of what happened. What were the circumstances leading up to the
incident? Attach additional sheets if necessary.
Commonwealth of Pennsylvania
Unusual Incident Report Form
Page 1
Department of Aging
01/15
OLDER ADULT DAILY LIVING CENTER
Unusual Incident Report
6 Pa. Code § 11.16
FACILITY INFORMATION
Name of Facility:
License Number:
Address of Facility:
County:
Name of Director:
Telephone Number:
DATE AND TIME OF INCIDENT
Date:
Time:
AM
PM
TYPE OF INCIDENT: (Check all that apply)
Criminal conviction against the legal entity, owner, operator or employee as described in 6 Pa. Code § 11.281
Injury, trauma or illness of a client requiring treatment at a medical facility
Violation or suspected violation of a client’s rights
A client who is missing and presumed to be at risk (all elopements are considered reportable)
Abuse, neglect or exploitation or suspected abuse, neglect or exploitation of a client
Misuse or suspected misuse of a client’s funds or property
Outbreak of a communicable disease as defined in 28 Pa. Code § 27.2
An incident involving the fire department or circumstances requiring police action
A condition, except for snow or ice, that results in closure of the facility for more than one scheduled day of operation
Client death, that occurs at the center per 6 Pa. Code § 11.17
CLIENT INFORMATION
Name of Client: (Last, First)
Sex
Date of Birth
M:
F:
Funding Source
Aging Waiver
COMMCARE
Independence
OBRA
Options
Private
Other (Specify) ______________________
LOCATION OF INCIDENT: (Bathroom, Program Area, Center Grounds, etc)
DESCRIPTION OF INCIDENT: Provide a detailed description of what happened. What were the circumstances leading up to the
incident? Attach additional sheets if necessary.
Commonwealth of Pennsylvania
Unusual Incident Report Form
Page 1
Department of Aging
01/15
FOLLOW UP ACTION TAKEN: What action was initiated or is planned in response to the incident? Attach supporting documents if
applicable. (i.e. revised care plans, progress or treatment notes, revised policies/procedures, in-service training, etc). Address
measures taken to reduce the risk of repeat incidents at the conclusion of the investigation, if applicable. Include referrals if applicable.
NOTIFICATION
Department of Aging - Division of Licensing
Yes
Telephone
Date:
No
Written
Time:
Funding Agency
Yes
Telephone
Date:
(specify)
No
Written
Time:
Client’s Responsible Person
Yes
Telephone
Date:
(specify relationship)
No
Written
Time:
Local MH/MR Office
Yes
Telephone
Date:
(if applicable)
No
Written
Time:
ABUSE/NEGLECT/EXPLOITATION/ABANDONMENT & ACT 13 MANDATORY ABUSE NOTIFICATION (if applicable)
Local Area Agency on Aging (All Suspected Abuse, Neglect,
Yes
Telephone
Date:
Exploitation, Abandonment & Act 13 Reports)
No
Written
Time:
Law Enforcement (For Act 13 Reports)
Yes
Telephone
Date:
No
Written
Time:
Department of Aging - Criminal History Background Check Unit
Yes
Telephone
Date:
(Call 717-265-7887 to report Act 13 - serious physical, serious bodily,
No
Written
Time:
sexual abuse or suspicious death)
CONTACT INFORMATION
Name and Title of Person Completing Report:
Telephone Number of Contact Person:
Date of Report:
Time of Report:
AM
PM
Signature of person completing report:
SUMMARY OF REGULATORY REPORTING REQUIREMENTS
§ 11.16(b) - The responsible party, the client’s family, if appropriate, and the residential services provider, if applicable, shall be
immediately notified in the event of an unusual incident relating to a client.
§ 11.16(c) - In cases of abuse or suspected abuse, an incident
-
§ 11.16(d)
Within 3 working days after an unusual incident
involving a fire department, or circumstances requiring police
occurs, the center operator shall conduct an investigation of the
action, within 24 hours after an unusual incident occurs but not
unusual incident and complete and send copies of an unusual
later than the next working day, the center operator shall orally
incident report on a form specified by the Department to the
notify the following: (1) The Department. (2) The funding agency
following: (1) The Department. (2) The funding agency when the
when the services of the client involved in the unusual incident are
services of the client involved in the unusual incident are being
being publicly funded. (3) The mental health and mental
publicly funded. (3) The mental health and mental retardation
retardation program of the county in which the center is located if
program of the county in which the center is located if the client
the client involved in the unusual incident has mental illness or
involved in the unusual incident has mental illness or mental
mental retardation.
retardation.
REPORTING INSTRUCTIONS
Print the report for your records. Email the report to ADLC-UIReport@pa.gov.
Do not abbreviate words or use acronyms.
FOR DEPARTMENT OF AGING USE ONLY:
Date report received:
Reviewed by:
Commonwealth of Pennsylvania
Unusual Incident Report Form
Page 2
Department of Aging
01/15
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