Maine Department of Health and Human Services

OFFICE OF AGING AND DISABILITY SERVICES

REPORTABLE EVENT

☐ Dangerous Situation ☐ Death ☐ Emergency Department Visit ☐ Emergency Restraint ☐ Hospital Admission – Planned/Unplanned ☐ Law Enforcement Intervention ☐ Lost or Missing Person ☐ Medical Treatment Other Than Hospital ☐ Medication Error ☐ Physical Plant Disaster ☐ Physical Assault/Altercation ☐ Rights Violation ☐ Serious Injury ☐ Suicide Attempt ☐ Suicide Threat ☐ Transportation Accident
IDENTIFYING INFORMATION
Client First Name	Client Last Name	Gender M/F	Date of Birth:	Social Security Number
Event Start Date	Event Start Time	Event End Date	Event End Time
INFORMATION REGARDING DIRECT REPORTING TO DHHS
Date Reported to DHHS:	DHHS Person Reported To:
Department Reported to ☐ DS Caseworker ☐ DS Crisis ☐ DS Regional Supervisor/PA ☐ Incident Data Specialist (EIS entry only)
PROGRAM TYPE AND INCIDENT LOCATION INFORMATION
Program Type: ☐ DS Home Supports ☐ DS Community Supports ☐ DS Employment Support ☐ DS Crisis ☐ Other (Specify):
Incident Location: ☐ DS Community Support ☐ DS Crisis ☐ DS Employment Support ☐ DS Home Support ☐ In Community ☐ Hospital ☐ Nursing Facility ☐ Personal Residence ☐ Other (Specify):
REPORTABLE EVENT INFORMATION
Short Description of Event: (Limit to 4000 Character)
Short Description of Actions Taken: (Limit to 4000 Character)
REPORTER DETAILS (Person Who Had A Role In This Event)
Reporter Name:	Address:
Work Telephone:	E-mail Address:	Title:
Reporter Type: (Reporter’s relationship to the individual who is the subject of the report) ☐ Consumer ☐ Caseworker ☐ Family Member ☐Guardian ☐ DS Provider Direct Care ☐ DS Provider/Manager/Supervisor ☐ DS Crisis Team ☐ DS APS Intake Unit ☐ Other (Specify):
Reporter Role: ☐ Participant in event ☐ Witness ☐ Hearsay ☐ Other (Specify):
Method of Reporting: ☐ Call ☐ E-mail ☐ Fax ☐ Hand-delivered to DHHS ☐ In-Home Visit ☐ Letter ☐ Other (Specify):
AGENCY CONTACT / FILER DETAILS (Person/Agency Responsible For Content And Reporting To DHHS)
Filer Type: ☐ Agency Staff ☐ State Staff ☐ Family Member ☐ Guardian ☐ APS Intake (OES) ☐ Other (Specify):
Name:	Phone Number:	E-mail :	Information Received: ☐ AM Date: Time: ☐PM
Provider or Agency/Address Location:
WORKER DETAILS
Was Worker(s) involved in event? ☐ Yes ☐ No ☐ Unknown Name(s):
Worker Type: ☐ Direct Service ☐ Management/Supervisor ☐ Other (Specify): Role: ☐ Participant ☐ Witness ☐ Other (Specify):
Was another Person(s) involved in event? ☐ Yes ☐ No ☐ Unknown Names(s): Role: ☐ Participant ☐ Witness ☐ Other (Specify):
FAMILY/GUARDIAN NOTIFICATIONS
Guardian Notified? ☐ Yes ☐ No ☐ No Guardian If Yes, Who Notified Guardian?
Guardian Name:	Address:	Phone:
Client Name:
ADULT DEVELOPMENTAL SERVICES EVENT TYPES & CATEGORIES Reportable Events must be received by DHHS within 1 business day of the event.
DANGEROUS SITUATION 14-197 CMR CH12 2A xvi
Type of Dangerous Situation: ☐ Arson ☐ Hostage taking ☐ Other Event that poses jeopardy to client and/or public safety that is not listed in other categories (Specify):
Was emergency services called: ☐ Yes ☐ No
If yes, indicate type? ☐ Ambulance/rescue/paramedics ☐ Law Enforcement ☐ Fire Department ☐ Warden Service ☐ Crisis Team ☐ Other (Specify):
DEATH 14-197 CMR CH12 2A i
Death was: ☐ Expected ☐ Unexpected
Preliminary Cause of Death? ☐ Natural causes – age related ☐ Complications due to illness or other diagnosis ☐ Suicide - completed ☐ Homicide ☐ Accidental Death:
Location at time of death? ☐ Private Home ☐ Agency Home ☐ Nursing Facility ☐ Hospital ☐ Hospice ☐ Assisted Living Facility ☐ Other (specify):
EMERGENCY DEPARTMENT VISIT 14-197 CMR CH12 2A iv
Please indicate method of transportation to Emergency Department: ☐ Call to 911 – member transported to Emergency Department ☐ Agency transported member to Emergency Department ☐ Member took self to Emergency Department ☐ Family/others took member to Emergency Department
EMERGENCY RESTRAINT 14-197 CMR CH12 2Axiv
Type of Restraint ☐ Personal Holding ☐ Chemical ☐ Blocking	If restraint was a personal holding, please indicate type? ☐ 1 Person ☐ 2 Person
Is there an approved behavior plan in place? ☐ Yes ☐ No	Single or Multiple Restraint ☐ Single ☐ Multiple
SINGLE RESTRAINT INFORMATION
Single restraint start time:	Single restraint end time:
Total restraint time:
MULTIPLE RESTRAINT INFORMATION
Multiple restraint – Start time of first restraint:	Multiple restraint – End time of last restraint:
Total Multiple restraint time:	Duration of each restraint:
HOSPITAL ADMISSION PLANNED/UNPLANNED 14-197 CMR CH12 2A v
Why was the member admitted: ☐ Admission ☐ Observation
LAW ENFORCMENT INTERVENTION 14-197 CMR CH12 2A xi
Type of Intervention: ☐ Individual receiving services involved with criminal activity ☐ Individual receiving services involved is part of a police investigation ☐ Individual receiving services is a victim of a crime ☐ Crisis intervention involves police or law enforcement personnel
LOST OR MISSING PERSON 14-197 CMR CH12 2A ix
Indicate time member was missing: ☐ Less than 5 hours ☐ 5-10 hours ☐ More than 10 hours
Did member runaway? ☐ Yes ☐ No
MEDICAL TREATMENT OTHER THAN HOSPITAL 14-197 CMR CH12 2A vii
Reason for seeking treatment: ☐ Medical Condition ☐ Flu ☐ Other (Specify):
Where did person receive treatment? ☐ Physician’s Office ☐ Urgent Care ☐ Other (Specify):
MEDICATION ERROR 14-197 CMR CH12 2A vi
Please list name(s) of medication(s) involved:
Type of Error? ☐ Refusal to take prescribed medication ☐ Incorrect route ☐ Incorrect method of administration ☐ Incorrect dosage ☐ Incorrect schedule ☐ Took medication that was not prescribed to the individual receiving services ☐ Individual receiving services had an allergic reaction ☐ Did not follow procedures when assisting member with self-medication
Reason medication error occurred? ☐ Administration error ☐ Supply exhausted ☐ Forgot ☐ Refusal ☐ Prescription unfilled ☐ Incorrect chart entry ☐ Non-compliance ☐ Forgot to take on activity ☐ Forgot to send to program ☐ Other (Specify):
PHYSICAL ASSAULT/ALTERCATION 14-197 CMR CH12 2A xiii
Individual receiving services initiates a physical altercation with: ☐ Staff ☐ Another individual receiving services ☐ Member of the Community ☐ Other (Specify):
Was the individual physically assaulted by another individual receiving services? ☐ Yes ☐ No
Was Emergency Services involved? ☐ Yes ☐ No If yes, indicate type: ☐ Ambulance ☐ Rescue/Paramedics ☐ Law Enforcement ☐ Crisis Outreach Team ☐ Other Emergency Service (specify):
PHYSICAL PLANT DISASTER 14-197 CMR CH12 2A x
Type of disaster: ☐ Fire ☐ Flood ☐ Natural Disaster ☐ Other incident that caused displacement (Specify):
RIGHTS VIOLATION 14-197 CMR CH12 2A xv
Type of Rights Violation: ☐ Behavior Modification ☐ Communications ☐ Discipline ☐ Humane Treatment ☐ Medical Care ☐ Nutrition ☐ Personal Property ☐ Physical Exercise ☐ Religious Practice ☐ Records ☐ Social Activity ☐ Voting ☐ Work
SERIOUS INJURY 14-197 CMR CH12 2A viii
Type of Injury: ☐ Laceration requiring sutures or staples ☐ Bone fracture ☐ Joint dislocation ☐ Loss of limb ☐ Serious burn ☐ Skin wound due to poor care
Cause of Injury? ☐ Accident ☐ Medical condition (seizures, etc) ☐ Treatment error (medication reaction, etc.) ☐ Origin unknown ☐ Other (Specify):
Where did person receive treatment? ☐ Emergency Room ☐ Outpatient services other than emergency room ☐ Inpatient ☐ Physician’s office ☐ Emergency intervention on site ☐ Other (specify):
SUICIDE THREAT 14-197 CMR CH12 2A iii
Type of threat: ☐ Made a verbal threat to kill themselves ☐ Describes a way to carry out a suicide plan ☐ Talks or writes about death or suicide
TRANSPORTATION ACCIDENT 14-197 CMR CH12 2A xii
Type of Transportation Accident: ☐ Individual receiving services is a pedestrian ☐ Individual receiving services is a cyclist ☐ Individual receiving services is a passenger in motorized vehicle-includes ATVs ☐ Individual receiving services is involved in a watercraft accident