Internal Incident Report

Incident relates to:

Program

Location

Location of Incident if other than Affinity Site:

Street Address

Street Address Line 2

CityState

Zip Code

Name of Person Served

First NameLast Name

Date of Incident:

Date

Time of Incident:

Hour Minutes

AM/PM Option

Name of staff reporting incident:

First NameLast Name

Email of staff reporting incident:

example@example.com

Supervisor of staff person who responded to the incident:

First NameLast Name

Supervisor email

example@example.com

911 Emergency Services Used

Was This a Medical Emergency?

Was this a behavioral incident that resulted in a call to 911;

Mobile Mental Health Crisis (COPE)

Did Affinity staff use a manual restraint (EUMR)?

Was an as needed (PRN) medication used to intervene in a behavioral incident?

Is there Serious Injury or Death?

In the event of death or serious injury, call the COO at 952-242-9139

Serious injuries include the following:

Fractures
Dislocations
Evidence of internal injuries
Head injuries with loss of consciousness or potential for a closed head injury or concussion without loss of consciousness requiring a medical assessment by a health care professional, whether or not further medical attention was sought
Lacerations involving injuries to tendons or organs and those for which complications are present
Extensive second degree or third degree burns and other burns for which complications are present
Extensive second degree or third degree frostbite, and other frostbite for which complications are present
Irreversible mobility or avulsion of teeth
Injuries to the eyeball
Ingestion of foreign substances and objects that are harmful
Near drowning
Heat exhaustion or sunstroke
Attempted suicide
All other injuries and incidents considered serious after an assessment by a health care professional, including but not limited to self-injurious behavior, a medication error requiring medical treatment, a suspected delay of medical treatment, a complication of a previous injury, or a complication of medical treatment for an injury

External Property Management Company Summary (PPL)

A description of what happened, without identifying other persons served.

Provide a description of the incident:

Do not use identifying information, such as names or initials, if the incident involved another person receiving services.

Provide a description of staff response to the incident:

Do not use identifying information, such as names or initials, if the incident involved another person receiving services.

Were relevant policies and procedures followed?

Other

If no, explain.

Were relevant policies and procedures adequate?

Other

If no, explain.

Is the incident similar to past events with the persons or the services involved?

If yes, identify the incident patterns.

Is there a need for corrective action by the program to protect the health and safety of the persons receiving services and to reduce future occurrences??

If yes, identify the corrective action plan designed to correct current lapses and prevent future lapses in performance by staff or the program. (Include applicable implementation dates, staff assigned to take the corrective action, and attach relevant documentation.)

Were coordinated service and support plan addendum(s), applicable to the person and incident, implemented for the person(s) involved?

Other

Were Affinity Care - 245D policies and procedures, applicable to the incident, implemented as written?

Other

If other staff responded to the incident, please include their names:

Case Manager:

First NameLast Name

Case Manager Email

example@example.com

Case Manager Phone:

Please enter a valid phone number.Format: (000) 000-0000.

Date Notified:

Date

Time Notified

Hour Minutes

AM/PM Option

Legal Representative or Designated Emergency Contact:

First NameLast Name

Date Notified:

Date

Time Notified

Hour Minutes

AM/PM Option

Signature of reporting staff:

Date signed:

Date

Name of staff conducting internal review:

First NameLast Name

Signature of staff completing internal review:

Date Signed

Date

Internal Incident Report

Details of the Incident

Staff Response to the Incident

Persons Notified