You will find these details to a large extent on the invitation to file the tax return. ... Date of birth M F Bank account for tax refund Spouse/ partner Name and ...
Report CopyRight/DMCA Form For : Policy Incident Reporting Amp Management
DDRS Policy Manual Effective Date Mar 1 2011, Policy Number BQIS 460 0301 008 Incident Reporting Review. v economic deprivation,vi threats of violence,from a spouse or cohabitant intimate partner. 2 Alleged suspected or actual neglect which must also be reported to Adult Protective Services or. Child Protective Services as indicated which includes but is not limited to. a failure to provide appropriate supervision care or training. b failure to provide a safe clean and sanitary environment. c failure to provide food and medical services as needed. d failure to provide medical supplies or safety equipment as indicated in the Individualized. Support Plan ISP, 3 Alleged suspected or actual exploitation which must also be reported to Adult Protective. Services or Child Protective Services as indicated which includes but is not limited to. a unauthorized use of the,i personal services,ii personal property or finances or. iii personal identity,of an individual, b other instance of exploitation of an individual for one s own profit or advantage or for the. profit or advantage of another, 4 Peer to peer aggression that results in significant injury by one individual receiving services to. another individual receiving services, 5 Death which must also be reported to Adult Protective Services or Child Protective Services as. indicated Additionally if the death is a result of alleged criminal activity the death must be. reported to law enforcement, 6 A service delivery site with a structural or environmental problem that jeopardizes or. compromises the health or welfare of an individual. 7 A fire at a service delivery site that jeopardizes or compromises the heath or welfare of an. individual, 8 Elopement of an individual that results in evasion of required supervision as described in the ISP. as necessary for the individual s health and welfare. 9 Missing person when an individual wanders away and no one knows where they are. 10 Alleged suspected or actual criminal activity by an individual receiving services or an employee. contractor or agent of a provider when, a the individual s services or care are affected or potentially affected. b the activity occurred at a service site or during service activities or. c the individual was present at the time of the activity regardless of location. 11 An emergency intervention for the individual resulting from. a a physical symptom,b a medical or psychiatric condition. c any other event, 12 Any injury to an individual when the cause is unknown and the injury could be indicative of. abuse neglect or exploitation, 13 Any injury to an individual when the cause of the injury is unknown and the injury requires. medical evaluation or treatment,DDRS Policy Manual Effective Date Mar 1 2011. Policy Number BQIS 460 0301 008 Incident Reporting Review. 14 A significant injury to an individual that includes but is not limited to. a a fracture, b a burn including sunburn and scalding greater than first degree. c choking that requires intervention including but not limited to. i Heimlich maneuver,ii finger sweep or,iii back blows. d bruises or contusions larger than three inches in any direction or a pattern of bruises or. contusions regardless of size, e lacerations which require more than basic first aid. f any occurrence of skin breakdown related to a decubitus ulcer regardless of severity. g any injury requiring more than first aid, h any puncture wound penetrating the skin including human or animal bites. i any pica ingestion requiring more than first aid. 15 A fall resulting in injury regardless of the severity of the injury. 16 A medication error or medical treatment error as follows. a wrong medication given,b wrong medication dosage given. c missed medication not given,d medication given wrong route or. e medication error that jeopardizes an individual s health and welfare and requires medical. 17 Use of any aversive technique including but not limited to. a seclusion i e placing an individual alone in a room area from which exit is prevented. b painful or noxious stimuli,c denial of a health related necessity. d other aversive technique identified by DDRS policy. 18 Use of any PRN medication related to an individual s behavior. 19 Use of any physical or mechanical restraint regardless of. a planning,b human rights committee approval,c informed consent. Responsible Parties, 1 The provider responsible for an individual at the time of the occurrence of a reportable incident. shall submit an incident initial report, 2 In addition to the provider s mandatory reporting any other person may submit an incident initial. report associated with any reportable incident, 3 The entity responsible for incident follow up reports is the individual s. a case manager when receiving waiver funded services. b residential provider s Qualified Developmental Disabilities Professional QDDP when. receiving State Line Item SLI Supervised Group Living SGL or other ICF MR. DDRS Policy Manual Effective Date Mar 1 2011, Policy Number BQIS 460 0301 008 Incident Reporting Review. c provider staff when receiving Caregiver Supports Services. d BDDS service coordinator when receiving other services e g Title XX and nursing. facilities, Ensuring the safety of individuals receiving services. 1 When a reportable incident is discovered in which an Individual receiving services is determined. to be in danger the person making the discovery shall. a call 911 if indicated, b initiate safety actions for the Individual as is indicated and as is possible. c contact the following and notify them of the situation. i in supported living settings the Individual s case manager or the case. management vendor s 24hr crisis line if the case manager is not immediately. ii a manager with the responsible provider company. iii the BDDS District Manager and, iv Adult Protective Services or Child Protective Services as indicated and. v Individual s legal representative, 2 Providers DDRS staff and the case management vendor staff shall follow the BDDS Imminent. Danger Policy in mitigating the danger to the individual. Initial incident reporting to BQIS, 1 Within 24 hours of initial discovery of a reportable incident the reporting person shall file an. incident initial report with BQIS using the DDRS approved electronic format available at. https ddrsprovider fssa in gov IFUR In the event of a network malfunction incident initial. reports and incident follow up reports may be e mailed to BDDSIncidentReports fssa in gov or. faxed to 260 482 3507, 2 The reporting person shall be descriptive when completing the narrative portions of the incident. initial report form including,a a comprehensive description of the incident. b a description of the circumstances and activities occurring immediately prior to the. c a description of any injuries sustained during the incident. d a description of both the immediate actions that have been taken and actions that are. planned but not yet implemented and, e a listing of each person first name last initial involved in the incident with a. description of the role and staff title if applicable of each person involved. 3 Exhibit A of this policy contains additional directives for providing comprehensive and. objective information on the incident initial report. Notifying additional entities of incident,DDRS Policy Manual Effective Date Mar 1 2011. Policy Number BQIS 460 0301 008 Incident Reporting Review. 1 Within 24 hours of initial discovery of a reportable incident the reporting person shall forward a. copy of the electronically submitted incident initial report to. a APS or CPS as indicated for all incidents involving. i alleged suspected or actual abuse,ii alleged suspected or actual neglect. iii alleged suspected or actual exploitation,b the individual s BDDS service coordinator. c the individual s residential provider when receiving residential services. d the individual s case manager when receiving services funded by waiver. e all other service providers identified in the individual s Individualized Support Plan and. 2 Within 24 hours of initial discovery of a reportable incident the reporting person shall notify the. individual s legal representative if indicated,Reportable Incident Follow Up. 1 An incident may be closed by BQIS upon receipt and processing. 2 If an incident is not closed upon BQIS receipt and processing BQIS shall forward an email. notification to the person responsible for incident follow up reporting. 3 The person responsible for incident follow up reporting shall. a submit an electronic incident follow up report within 7 days of the date of the incident. initial report, b continue to submit incident follow up reports on an every 7 day schedule until such. time as the incident is resolved to the satisfaction of all entities. c forward copies of each follow up report to the same entities who received a copy of the. incident initial report, 4 Exhibit B of this policy contains additional directives for providing comprehensive and. objective information on the incident follow up report. Provider Internal Incident Reports, 1 Any internal provider incident report addressing services to an individual that is determined by. the provider to not meet the criteria of a reportable incident as described in this policy shall be. made available to,a an individual s case manager or. b any representative of DDRS Indiana State Department of Health ISDH or the Office. of Medicaid Policy and Planning OMPP upon request,Maintenance of Incident Report Data. 1 A provider shall maintain all documentation related to incident reporting whether in electronic. format or other format for at minimum 7 years,DDRS Policy Manual Effective Date Mar 1 2011. Policy Number BQIS 460 0301 008 Incident Reporting Review. Contact Information for Incident Reporting Management. Questions regarding incident management reporting can be directed to the BQIS Incident Reporting. Department through e mail BDDSIncidentReports fssa in gov or telephone 260 482 3192. DEFINITIONS, BDDS means Bureau of Developmental Disabilities Services as created under IC 12 11 1 1 1. BQIS means Bureau of Quality Improvement Services as created under IC 12 12 5. DDRS means the Division of Disability and Rehabilitative Services as established by IC 12 9 1 1 a. division within FSSA in which the bureau of quality improvement services BQIS is located. Emergency intervention means the use of restrictive interventions during a behavioral emergency only. as necessary to protect an individual or others from harm. Mandated reporter means all provider staff case managers service coordinators BQIS staff physicians. or other related person Mandated reporters are required to report alleged suspected or actual abuse. neglect or exploitation of an individual and any other incident that meets the criteria of a reportable. Qualified Developmental Disabilities Professional or QDDP means a person who. a integrates,b coordinates and,c monitors an Individual s services. when the Individual is not receiving Case Management services. State Line Item or SLI means a funding source for services authorized by DDRS using 100 state. dollars obligated within available resources to support Adult individuals who have been determined. eligible for developmental disabilities services by the BDDS when all other possible resources including. Medicaid are unavailable, Service coordinator means a person providing service coordination services under IC 12 11 2 1. OMPP means the Office of Medicaid Policy and Planning as established by IC 12 8 6 1. REFERENCES,IC 12 10 3,DDRS Policy Manual Effective Date Mar 1 2011. Policy Number BQIS 460 0301 008 Incident Reporting Review. Interpretive Guidelines Intermediate Care Facilities For Persons With Mental Retardation Rev. BDDS Imminent Danger Policy,BDDS Aversive Technique Policy. BDDS Use of Restrictive Interventions including Restraint Policy. BDDS Quality Assurance and Quality Improvement Policy. BDDS Human Rights Committee Policy,BDDS Protection of an Individual s Rights Policy. Approved by Julia Holloway DDRS Director,DDRS Policy Manual Effective Date Mar 1 2011. Policy Number BQIS 460 0301 008 Incident Reporting Review. INCIDENT INITIAL REPORT, Note Sections 1 5 are to be completed by the reporting person. Section I Consumer Information Section all fields are required in this section. SSN Enter the Social Security number of the individual. NAME FIRST AND LAST Enter the first and last name of the individual. ADDRESS Enter the home address city state and zip code where the. individual resides,DOB Enter the date of birth of the individual. COUNTY Enter the name of the county in which the individual resides. GENDER Select the appropriate box male or female, PRIMARY FUNDING SOURCE Select the primary funding source for the individual. AFC adult foster care,AUTISM WAIVER,CFC child foster care. NURSING HOME,SLI RESIDENTIAL,SUPP SRV WAIVER, Section 2 Informed Section all fields are required in this section. APS CPS Name Date County Phone Method of Notification. RESIDENTIAL PROVIDER BDDS Select N A or Yes as appropriate. HAB VOC PROVIDER BDDS Select N A or Yes as appropriate. OTHER PROVIDER Select N A or Yes as appropriate,LEGAL GUARDIAN Name date notified. BDDS SC BDDS Select appropriate service coordinator name from the drop. down box date notified, CASE MANAGER if appropriate Select appropriate case manager name from the drop down. box date notified,QDDP if appropriate Name date notified. POLICE if appropriate Date notified,CORONER if appropriate Name date notified. Section 3 Supervision Provided by Section, INDIVIDUAL SUPERVISING AT TIME OF Enter the name of the individual who was responsible for. INCIDENT BDDS supervision at the time of the incident. RESPONSIBLE SUPERVISORY PROVIDER BDDS Select the responsible supervisory provider from the drop. DDRS Policy Manual Effective Date Mar 1 2011, Policy Number BQIS 460 0301 008 Incident Reporting Review. Section 4 Reporting Person and Agency Section, NAME FIRST AND LAST Enter the first and last name of the person submitting the. POSITION Indicate the position e g case manager service coordinator. direct care staff team leader etc of the person submitting. the report, PHONE NUMBER AND EXTENSION Enter the phone number and extension of the person. submitting the report,DATE REP0RT SUBMITTED Date is auto populated. REPORTING AGENCY Select the agency employing the person submitting the report. as applicable from the drop down box If the person is self. employed enter self, E MAIL ADDRESS Enter the e mail address of the person submitting the report. Section 5 Incident Information, INCIDENT DATE AND TIME Include the date and time of the reported incident. DATE OF KNOWLEDGE The date the reporting person became aware of the incident. WHERE OCCURRED Select the location from the drop down box. AFC adult foster care,Community Hab,Community Job,Fac Hab ADC ADL. Home family,NF nursing facility,SGL supported group living ICF DD setting. Other explain, IS THIS INCIDENT REGARDING THE DEATH OF Select appropriate answer yes or no. THIS CONSUMER If Yes additional questions must be answered. IS THIS INCIDENT REGARDING A PRN THAT Select appropriate answer yes or no. WAS ADMINISTERED TO THIS CONSUMER If Yes additional questions must be answered. WERE POLICE INVOLVED Select appropriate answer yes or no. WAS THE CONSUMER HANDCUFFED Select appropriate answer yes or no No is default. WAS THE CONSUMER TASERED Select appropriate answer yes or no No is default. DESCRIBE THE INCIDENT Describe the incident circumstances and activities taking place. immediately prior to the incident Include a description of any. injuries that are a result of the incident Identify all. participants first name last initial along with their. involvement in the incident Be comprehensive but concise in. describing the incident who what where when and how. Be objective, PLAN TO RESOLVE IMMEDIATE AND LONG Include both the immediate actions that have been taken since. TERM the incident occurred and actions that have not yet been. implemented For example staff suspension in the event of. an allegation of abuse neglect or exploitation staff in service. additional monitoring review revision of ISP BSP review of. policies procedures etc,DDRS Policy Manual Effective Date Mar 1 2011. Policy Number BQIS 460 0301 008 Incident Reporting Review. INCIDENT FOLLOW UP REPORT, Note To be completed by the person responsible for follow up. NAME FIRST AND LAST Enter the first and last name of the individual. SSN Enter the Social Security Number of the individual. AGENCY Select BDDS from the drop down box, INCIDENT NUMBER Enter the Incident Number provided upon submission of the. initial incident and included in the e mail received regarding. the Incident Initial Report,INCIDENT DATE Enter the date of the incident. DESCRIBE INVESTIGATION INTO THE INCIDENT Be thorough and complete. AND OR ALL OTHER FOLLOW UP ACTIONS, DESCRIBE SYSTEMIC ACTIONS BEING TAKEN TO Be thorough and complete Include person s responsible. ENSURE HEALTH AND WELFARE ISSUES Include the actions being taken to prevent future occurrences. of a similar nature, IF ABUSE NEGLECT OR EXPLOITATION WAS Select appropriate answer from the drop down box. REPORTED WAS IT SUBSTANTIATED, NAME OF PERSON SUBMITTING REPORT Enter the first and last name of the person submitting the. follow up report, TITLE OF PERSON SUBMITTING REPORT Enter the title of the person submitting the follow up report. AGENCY SUBMITTING REPORT Select agency from the drop down box. DATE REPORT SUBMITTED The date is automatically filled in by the software program. TELEPHONE NUMBER OF PERSON SUBMITTING Enter the telephone number of the person submitting the. REPORT follow up report, E MAIL ADDRESS OF PERSON SUBMITTING Enter the e mail address of the person submitting the follow.
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