Get Keystone First Chckf_18360419 2018-2025

Filling out the Keystone First CHCKF_18360419 online is an essential process for reporting critical incidents in Community HealthChoices. This guide will provide you with comprehensive and clear instructions on how to navigate each section of the form effectively.

Follow the steps to fill out your form accurately.

1. Press the ‘Get Form’ button to access the form and open it in the appropriate editor.
2. Begin by entering the provider or facility information, which includes your National Provider Identifier (NPI), phone number, agency name, and address details such as city, state, and ZIP code.
3. Next, provide the details of the reporting party, including the reporter’s first name, last name, title, email, and phone number. If there is a different point of contact for discussing the incident, include their information as well.
4. Complete the participant’s information by entering their Medicaid number, address, city, date of birth, state, age, ZIP code, and gender.
5. Fill in the service coordinator’s information if applicable, providing their name, address, city, state, email, ZIP code, and phone number. Indicate whether they contacted the participant within 24 hours of discovering the incident.
6. Document the incident's details, including the date and time it occurred, whether it was witnessed, and the date it was discovered. Note who learned about the incident, specifying the location type.
7. List any witnesses present during the incident, including their names, initials, and their relation to the participant.
8. Indicate whether services were being provided at the time of the incident and, if so, specify the service name.
9. Ensure you report if the service coordinator and the guardian were informed of the incident, along with relevant dates.
10. Provide a comprehensive description of the incident, noting all relevant details, immediate resolutions taken, and proposed prevention plans.
11. Check all applicable incident types from the provided list and indicate how the injury occurred.
12. In the resolution section, describe any resolutions and actions undertaken regarding the incident, including changes to staffing, participant care plans, or environment updates if applicable.
13. Once all sections are completed, save your changes, and ensure you have downloaded or printed the form as needed. You may also share it with relevant parties.

Complete your Keystone First CHCKF_18360419 form online today to ensure timely reporting of critical incidents.