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Incident reports should be written only when you are sure that a persons rights have been violated. True False
Full names of consumers should never be used in an incident report (IR). Only initials and ID#s should be used. True False
Full names of staff involved in the incident should always be used True False
If you are not sure whether you should write an incident report (IR), you probably should not write it. True False
If I write an incident report (IR) about a potential rights issue, then I also need to call the Office of Recipient Rights and the case manager/supervisor to inform them of the incident
True False
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The purpose of an Incident Report (IR) is to report, review, evaluate and monitor unusual or unexpected incidents that occur in the course of providing services.
A communication tool between provider staff and clinical staff.
An organizational risk management tool used to evaluate any potential areas of harm, quality of care or risk is addressed
A Confidential Peer Review document
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At CSTS the incident report is considered a peer review document. It will never be made a part of the consumer case record (this includes but is not limited to the IPOS, progress notes, behavior plans, etc).
At CSTS Incident Reports are considered a peer review document
 It will never be a part of the case record
 Is not subject to court subpoena
 Disclosure or duplication of Incident Reports are absolutely prohibited
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Follow licensing guidelines for distribution of
Incident Reports
Once the incident report comes to CSTS, it then is part of the peer review process.
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An unusual event that disrupts or adversely affects the course of treatment or care of a consumer.
Unusual events should be identified on an individual case basis and may be different based on the individual consumer needs/treatment. Incidents may include but are not limited to: behavioral incidents, medication errors, hospitalizations, use of physical intervention , consumer death, etc.
Completing an Incident Report is not a “bad” thing. We
EXPECT to see them because they are a communication and risk management tool.
(CMHPSM policy: Incident Reporting)
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Anyone who witnesses an incident, or after the fact becomes aware of an incident MUST complete an Incident Report (IR)
◦ This includes: direct care staff, home managers, supervisors, program administrators, clinical staff, nurses and doctors
◦ Don’t wait for someone else to complete an Incident Report
◦ There should only be one incident report (IR) per consumer event.
If more than one consumer is involved in an incident each consumer’s full name and ID# incident report (IR) should be included on that
◦ Multiple Incident Reports are not necessary if more than one consumer is involved in an incident.
◦ It MUST be stressed that at any point when an incident occurs, the staff MUST attend to the individual first to ensure health and safety. Once that is done, the Incident Report (IR) can be completed
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What to include:
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Full name of consumer (do not use initials or ID #s without names)
◦ ID #
◦ Provider Name
◦ If other consumers are involved, include the full name and ID # of those folks
◦ The date, hour, location, and cause of the incident
◦ The effect of the incident on the person who was involved and the care given
◦ The names of the individuals who were notified (case manager, psychologist, ORR, family, guardian, etc) and the time of notification
Clear/concise statement regarding the extent of the injuries, treatment ordered, and the disposition of the person who was involved
◦ Corrective measures that were taken to prevent the incident from happening again
◦ Must be completed and submitted within 24 hours of the incident
◦ DO NOT ENTER A CODE.
THIS WILL BE DONE BY ORR
◦ IF the Incident Report is entered directly into E.II, it will automatically be forwarded to the supervisor of your agency
◦ Follow procedures of your provider agency
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ALL STAFF: completes the Incident Report (IR) either using the paper version or directly into E.II. Call the Office of Recipient Rights (ORR) with any potential rights issues within 24 hours of the incident
◦ PROVIDER STAFF
 If a paper version is completed, It should be written clearly, concisely and LEGIBLY . Staff send the report to their identified person within the organization to be scanned or entered into E.II within the 24 hour reporting period. E.II assumes that if the incident report (IR) is scanned that the supervisor has already signed off on the paper version. From there it is automatically routed to CSTS case manager/supports coordinator and Office of Recipient Rights.
 Once an incident Report (IR) is scanned into E.II, the paper version should be shredded unless you are in a licensed setting
 Follow the procedures of your provider agency
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Staff
Member
Completes an Incident
Report
Staff member routes IR to his or her supervisor
Provider sends IR to
WCHO/CSTS via EII
EII routes IR to Case
Manager
Supports
Coordinator and to the
Office of
Recipient
Rights
Case manager routes IR to other clinical team members and Clinical supervisor
After all clinical team members have signed off EII routes IR to
Performance
Improvement
Performance
Improvement uses IR information to report service delivery data to MDCH and to Project
Teams for improvement

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Providers: to look for quality improvement issues that may need to be addressed by the agency. (i.e. staffing patterns, training needs, supervision).
Assure that all of the necessary information is included and that what happened is clear and to correct any problems that are evident
Communicate issues/concerns with the clinical team
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CSTS Case manager/Supports Coordinators: to look for any clinical changes in a persons health, request for additional supports, or changes to services. Coordinate with providers.
Assure that all of the necessary information is included and that what happened is clear and follow up is occurring.
Assure any incident report (IR) that documents emergency use of physical management peer reviewers is routed to either the consumer’s behavioral psychologist (if applicable) or the behavior treatment committee chairperson (if behavioral psychologist is not involved with the person). Document what happened in the clinical record. Choose a set of additional including supervisor . (The supervisor must be included on all incident reports (IRs).
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CSTS Clinical (Psychologists/Occupational
Therapists/Peer Support Specialist, RN, RD, etc) : to look for any clinical changes in a persons health, request for additional supports, or changes to services. Coordinate with Providers
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Bob has been banging his head. There is a behavior plan in place for this. Staff document regularly on behavior logs about this behavior…does an incident report need to be written?
Bob has been banging his head. There is a behavior plan in place for this. Staff document regularly on behavior logs about this behavior. Today, Bob started biting his hand and has not done this before. Does an incident report (IR) need to be completed?
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Susan had a med change recently and refused to take her medication. What should you be looking at in this situation? Should an incident report be written?
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Office of Recipient Rights
Adult Protective Services
Child Protective Services
Sentinel Event Reporting
NO
NO
NO
NO
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Does reporting to one of the above meet the requirement for completing and Incident
Report?
NO
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If you have questions or need assistance on how to enter an Incident Report (IR) into E.II you can contact the WCHO Help Desk:
◦ 734.544.2991
◦ wchohelp@ewashtenaw.org
Or you can contact your supervisor for assistance
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As a provider agency, it is not my responsibility to code the incident report True False
Writing an incident report (IR) does not cover my obligation to report a potential rights violation
True False
A separate incident report should be written for each consumer involved in a particular incident
True False
Only initials and ID #’s of consumers should be used in incident reports (IRs) True False
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