72 Jaques Avenue• Worcester, MA01610-2480

Phone: 508-438-5578 Fax: 508-860-1023

Email:


Fax

To: / Donald Smith / From: / Phone:
Operations / Compliance Manager
Fax: / (508) 860-1023 / Pages: / 4
Phone: / (508) 438-5578 / Date: / September 27, 2018
Re: / Incident Report / CC:

UrgentFor ReviewPlease CommentPlease ReplyPlease Recycle

COMMUNITY HEALTHLINK, INC.

Incident/Accident Report

Client Name: / DOB:
Client Medical Record
Number: / Center/Division:
NorthCountyY&FS Worcester Adult
Program: / Date/Time of Incident:
Check appropriate box – Please only check one

CLIENT RELATED

1 / Death of client who is currently in or was recently discharged from a program (Complete DPPC Form as well) / 12 / Sexual assault by client toward other client
2 / Death of client while physically in a CHL program (Complete DPPC Form as well) / 31 / Physical assault by client toward other person
3 / Suicide or suicide attempt while in a CHL program resulting in serious injury and/or medical attention / 13 / Sexual activity by minors in CHL program property
29 / Suicide attempt or gesture not resulting in serious injury and/or medical attention / 14 / Missing client who is considered dangerous to self or others
4 / Serious injury to client while in a CHL program that requires medical treatment beyond first aid / 15 / Client under 18 years old who is absent from CHL program without authorization
9 / Self-injury requiring medical attention / 16 / Adult in DMH-funded program who is absent without authorization for more than 4 hours
5 / Medication reaction resulting in unanticipated reaction or event / 33 / Non-DMH client missing
6 / Medical emergency / 22 / Physical restraint
26 / Medical Non-Emergent / 35 / Physical Escort
7 / Minor injury to client / 23 / Substance-related incident (alcohol, legal and illegal drugs, other substances of abuse)
28 / Report of Abuse/Neglect Filed (DPPC, Elder Affairs - attach a copy) / 25 / Human Rights Violation
18 / Actual or potential emotional harm / 27 / Medication Error
8 / Assault toward client / 30 / Client arrested for a felony charge
10 / Criminal acts while in CHL program / 24 / Other:
11 / Incident involving weapon

STAFF RELATED

Staff ID#: / Staff Name:
100 / Criminal act / 105 / Infectious Material Exposure
101 / Medical emergency / 106 / Breach of Confidentiality
102 / Actual or potential emotional harm / 107 / Staff misconduct involving client care (for client complaint against staff, use Complaint Form)
104 / Work Related Injury (also complete FREI form) / 103 / Other:
108 / Alleged abuse of a client
FACILITIES RELATED
200 / Disaster Plan implementation / 204 / Theft
201 / Program or facility deemed uninhabitable or dangerous / 205 / Significant destruction of property
202 / Fire Hazard or Life Safety Hazard / 207 / Vehicle Damage (attach accident report)
203 / Infectious or hazardous materials involved in incident / 206 / Other:
Compliance: NFRN Initials: ______
Indicate which State Agency Involved / Department of Mental Health
Department of Children and Families
Department of Public Health
Department of Developmental Services / Department of Early Education and Care
Other:______
No State Agency Involvement
DMH Critical Incident Filed (please attach copy)
DESCRIPTION:
Describe the incident step-by-step (Attach additional sheets if necessary):
Initial Report Made to (Supervisor’s Name): / Date: Time:
STAFF INTERVENTION:
What measures were taken to ensure a safe environment? Explain.
If there was any exposure to bodily fluids, were universal precautions were used? N/A Yes No (Explain):
Was First Aid administered? Yes No
Was Medical Attention required? N/A No Yes (Give details):
Were other interventions were required? No Yes (Give details):
Urgent Event Form Completed? N/A Yes No
Other Information:

Signature of Person Completing Report ____________

Print Name of Person Completing Report
Job Title and Program

Date Completed 9/27/2018 4:38 PM

SUPERVISORY REVIEW
NOTIFICATION
Agency: / Person Notified, Title, Phone Number
Dept. of Mental Health
Dept. of Children and Families
Dept. of Early Education and Care
Dept. of Public Health
Dept. of Developmental Services
MBHP
Network Health
Fallon
NHP
BMC HealthNet
Other:
Physician
Parent and/or Guardian
Police Department
Fire Department
Human Rights Officer
Human Rights Committee
Human Resources
Other:

Resolution of Incident/Accident:

Corrective actions already taken/will be taken as soon as possible: N/A

Action to be taken to ensure this type of incident does not happen again: N/A

Signature of Supervisor Reviewing Report ____________

Print Name of Supervisor
Job Title and Program Date
PLEASE SEND A COPY TO: Don Smith, Operations/Compliance Manager Fax: (508) 860-1023
72 Jaques Avenue FAXED MAILED

Worcester, MA01610-2480 DATE:

DO NOT FAX OR MAIL THIS PAGE TO DONALD SMITH.

Incident and Accident Reporting Procedures

Instructions:

  1. Staff involved in or witness to any of the above incidents or accidents must complete an Incident/Accident Report Form.
  2. Critical incidents must be reported to the Center/Division Director within the time frame established by that Center/Division. Refer to the Center/Division incident reporting procedures.
  3. The Center/Division Director or the Supervisor must report critical incidents to the Vice President of Operations within 24 hours.
  4. The report should go to:

Donald Smith, 72 Jaques Avenue, Worcester, MA Fax: (508) 860-1023

  1. The Reviewing Supervisor should maintain a copy of the report to ensure the review loop is closed.
  2. Incident Reports are NOT to be included in the Client Record.

REPORTING PROTOCOL:

Follow the Protocol and Procedures established by your Center or Division for reporting to State Agencies:

1. DMH:

Category I incidents:

  • Report immediately by phone to 508-368-3838, M-F, 9-5. After hours call 508-368-3300 ask for the on-call for Critical Incidents.
  • Fax written report no later than next business day to : 5408-363-1500.

Category II incidents:

  • Report no later than the close of business on the next day by phone to: 508-368-3838
  • Fax written report no later than next business day to : 508-363-1500.
  1. The incident must be reported to the Department of Early Education and Care within 24 hours.
  1. The Department of Public Health must be called as soon as possible.
  1. The Department of Developmental Services must be called within 24 hours.
  1. The incident must be reported within 24 hours to the Disabled Persons Protection Commission and the Department of Children and Families.

FOR MORE INFORMATION ON INCIDENTS, SEE POLICY 5-04

Revised 9/11

SEND A COPY OF ALL REPORTS TO DONALD SMITH AT 72 JAQUES AVE FAX (508) 860-1023