Quality Assurance

Incident Reporting

Link to Consumer Incident Reporting form

Link to Report for Office of Licensure

Link to Non-Consumer Incident Reporting form

1. Allegations of consumers rights violations should be immediately reported to the RBHA advocate (not to exceed 24 hours from receipt of allegation).
2. Deaths and serious injuries should be reported in writing to DMHMRSAS within 24 hours of discovery & by telephone to the legally authorized representative; report to appropriate local authorities, as applicable, within 24 hours (police-if crime) by RBHA advocate.
3. Allegation/Incidents of abuse, neglect, and exploitation should be immediately reported to the human rights advocate, DSS, legally authorized rep, DMHMRSAS no less than 24 hours of discovery.

Report process:

Incident: any event or situation that is not consistent with the routine operation of the program or the routine care of a particular client or situation which represented an actual or potential threat to person or property.  An incident report is an agency form used to document an incident. An incident report must be completed for all incidents whether or not an injury occurred (including medication errors).

Completion of the forms: Follow the checklist above and complete the information appropriate for the particular incident.  If you need additional space for any items, please use the back of the form. Use brief, simple descriptions.

1. a. Report the incident to your supervisor immediately.
   b. If the incident involves alleged abuse of a consumer, call Adult Protective Services (APS) or Child Protective Services (CPS).
   c. If the incident involves death or serious injury, please complete DMHMRSAS form DMH 966 1156R04/16/0.
2. Complete the Consumer Incident Report and appropriate forms.
3. Submit the forms to the supervisor (or designee).
4. The supervisor (or designee) reviews for accuracy and signs the forms.
5. The supervisor (or designee) informs the Division Director of the incident.
6. The supervisor (or designee) makes 2 copies of all forms & submits copy to Division Director.
7. The supervisor hand delivers the originals to the Chief Executive Officer’s office within 24 hours.
8. The supervisor and/or staff involved may be contacted to clarify the event or be informed of any needed follow up.