Get Kentucky 1915 (c) Home And Community Based Services (hcbs) Waiver Programs - Incident Reporting Form

This guide provides a step-by-step approach to filling out the Kentucky 1915 (c) Home And Community Based Services (HCBS) Waiver Programs - Incident Reporting Form online. By following these instructions, users can ensure that all necessary information is accurately reported and submitted in a timely manner.

Follow the steps to accurately complete and submit the incident reporting form.

1. Press the ‘Get Form’ button to acquire the form and open it in your online document management system.
2. Begin by filling out the reporting source section. Include the program type by selecting from the options available: ABI, ABI-LTC, HCB, MIIW, MPW, or SCL. Indicate if participant-directed services are applicable.
3. Provide the waiver participant’s details. Enter their first name, last name, date of birth, social security number, and Medicaid number. If known, include any diagnosis or illnesses, as well as their race or ethnicity.
4. Complete the reporting agency information. Fill in your title, first and last name, and phone number, specifying whether you witnessed the incident.
5. Describe the incident in detail in the 'Incident Information' section. Choose between critical and non-critical incidents and select appropriate categories for the incident type.
6. Record the level of harm or injury to the waiver participant. Choose from the provided levels, and indicate the date and time of the incident and discovery.
7. In the next section, provide the location type where the incident occurred and fill in the address details. Describe the incident briefly, mentioning any staff involved and specific dates and times.
8. List notifications made regarding the incident. Include the entity notified, contact name, and the notification method.
9. If applicable, fill out the alleged perpetrator's information, providing as many details as available.
10. Document any witnesses to the incident, including their names, addresses, contact numbers, and relationships to the waiver participant.
11. Complete the risk mitigation section with the waiver participant’s current status and actions taken to ensure their safety.
12. Finally, the individual completing the form should print their name, add their title, sign, and date the form before submission.
13. Save changes to the document, then download, print, or share the completed form as needed.

Take action and complete your documents online today to ensure compliance and care for participants.