Get Ahca 15 Day Adverse Incident Report Form

Completing the Ahca 15 Day Adverse Incident Report Form is essential for documenting incidents within assisted living facilities. This guide provides an easy-to-follow process that ensures accurate and complete submission of the report online.

Follow the steps to successfully complete the form online.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Enter the required information about the assisted living facility. Fill in the facility's name as it appears on the license, the license number, street address, city, and telephone and fax numbers.
3. Provide the name of the person reporting the incident and their title.
4. Input required information about the resident involved in the incident, including their first and last name, Social Security number (if available), Medicaid number (if applicable), sex, and age.
5. If applicable, include information regarding the facility's risk manager, including name, credentials, and phone number.
6. Document the date of the incident and check the relevant outcomes that occurred as a result of the incident.
7. Clearly describe the circumstances of the incident, addressing who, what, where, when, and why. Use additional sheets if necessary.
8. If the incident involves issues of abuse, neglect, or exploitation, specify the immediate actions taken and whether authorities were notified.
9. For the 15-day report, provide the name and contact information for the resident's representative.
10. If the incident resulted in a transfer of the resident, indicate the location to which they were transferred and whether the Medical Examiner was contacted.
11. List the names and credentials of individuals involved in or witnessing the incident, and provide their relevant details.
12. Provide an analysis of the incident cause based on findings and outline corrective actions taken to prevent recurrence.
13. If you determine the incident does not meet adverse criteria, check the appropriate block; otherwise, complete the required signatures.
14. Once you have filled out all necessary sections, save any changes, and download, print, or share the form as needed.

Complete your incident report online today for effective documentation.