OCFS Reportable Events

OCFS Reportable Events

Demographics
Client Name / DOB / Mainecare#
Event Name / Event Date
Start Time / End Time
Event Details
Program Completing Form
(choose only one) / □ BHH
□ Crisis Unit
□ FFT
□ HCT
□ ICF/ID
□ Medication Management
□ MST/MST-PSB / □ Outpatient
□ RCS
□ Residential Treatment
□ TCM
□ Treatment Foster Care
□ Program Type Other ______
Incident Location: / □ Crisis Unit
□ Home Setting
□ Public Setting
□ Residential Placement:
/ □ Treatment Foster Home
□ Vehicle
□ Incidental Location Other:
______
If incident location is a residential placement, identify location / □ AMHC/Calais Children’s Residential
□ Becket/Auburn
□ Becket/Belgrade
□ Becket/Lewiston
□ Becket/Litchfield
□ Becket/Vermont Permanency Initiative
□ Crystal Strings
□ Easter Seals/Krol House
□ Easter Seals/Lancaster
□ Easter Seals/Zachary Rd
□GoodWill Industries
□ Granite Bay Care
□ Kidspeace/ Autism Spectrum DO Program
□ Kidspeace/Residential MH
□ Learning Ctr for Deaf/Walden
□ Leakes and Watts
□ NFI/Beacon
□ NFI/Bridge Crossing / □ NFI/Oliver Place
□ NFI/Riverbend
□ NFI/Stetson Ranch
□ NFI/Summit View
□ Northern Lighthouse
□ Piney Ridge
□ Spurwink/Augusta BH1
□ Spurwink/Augusta BH2
□ Spurwink/Augusta BH3
□ Spurwink/Brunswick
□ Spurwink/Casco
□ Spurwink/Chelsea
□ Spurwink/Cornville/Cadillac
□ Spurwink/Cornville/Katahdin
□ Spurwink/Cornville/Saddleback
□ Spurwink/Gardiner
□ Spurwink/Lewiston/Auburn/ Adams House
□ Spurwink/Lewiston/Auburn/ Meadow House
□ Spurwink/Pittston / □ Spurwink/SRP-Willow House
□ Spurwink/SRP/Brook St
□ Spurwink/SRP/River House
□ Sweetser/Belfast Staff Intensive
□ Sweetser/Belfast Staff Intensive 3
□ Sweetser/Hampden Staff Intensive
□ Sweetser/Portland Adolescent Unit
□ Sweetser/Rockport 1
□ Sweetser/Saco Family Focus
□ Sweetser/Saco Staff Intensive A
□ Sweetser/Saco Staff Intensive B
□ Sweetser/Saco Staff Intensive C
□ Sweetser/Saco Staff Intensive D
□ Sweetser/Winterport
□ The Opportunity Alliance/Edgewood
□ Residential Location Other:
______
Data Enterer
Data Enterer Name / Data Enterer Phone / Data Enterer email
Does this event need to be reported within 4 hours? Yes or No
Person Reporting Event
Reporter Name / Reporter Title / Reporter Phone
Reporter Email / Reporter Role:
□ Hearsay
□ Participant in Event
□ Witness
Reporter Role Other: ______
Other Involved in Event Yes or No / Name:
Name:
Name:
Name:
Name:
Guardian Notified Yes or No / Guardian Name: / Guardian Phone
Who notified guardian?
Category of event:
(choose all that apply) / □ Abuse/Neglect (by provider/Other client only)
□ Dangerous Situation
□ Death of a client
□ Medication Error (Not med refusals)
□ Restraints
□ Rights Violation
□ Serious Injury to client (only if happened during provision of service)
□ Suicide (not verbal threats/attempts)
Abuse/Neglect(by provider/other client only)
If abuse/neglect by parent/family member/caretaker, please only report to CPS. Only report abuse/neglect by provider(s) or other clients here in EIS
Summary of event: (describe abuse, Type? By Whom? Witnessed by others, self-reported or child disclosure? Include the location In which abuse occurred)
Response: (describe response to abuse; Has child received follow up for psychical/psychological well-being? Has CPS been contacted (provider self-report)?)
Physical Abuse
Abuse Type Details / Physical Yes or No
Abuse by Provider Yes or No / Staff/provider name
Abuse by another client Yes or No
Was client injured as result of abuse? Yes or No
Was Treatment Required? Yes or No
Treatment Location: (choose all that apply)
□ ER
□ Admitted to hospital
□ Physician’s Office / □ Crisis Assessment
□ Residence
□ Provider’s Office
Sexual Abuse/Exploitation
Sexual Abuse/Exploitation Yes or No
Abuse by Provider Yes or No / Staff/provider Name
Abuse by another client Yes or No / Type of Sexual Abuse: (Choose all that apply)
□ Visual Aggressor (Exposure)
□ Pornography
□ Inappropriate Conversations
□ Sexual Contact
Other: ______
Was Treatment Required? Yes or No
Treatment Location
(choose all the apply)
□ER
□ Physician’s Office / □ Crisis Helpline
□Sexual Assault line
Other ______
Forensic Assault Exam Performed? Yes or No
Neglect
Neglect Yes or No / Type of Neglect: (choose all that apply)
□ Deprivation of essential needs
□ Provider neglect (abandonment, inattentive to child, supervisory neglect, environment neglect, etc.)
□ Providers under influence
Abuse by Provider Yes or No / Staff/Provider Name
Verbal/Emotional
Abuse by Provider Yes or No / Staff/provider Name
Abuse by another client Yes or No
Dangerous Situation
Summary of Event: Summary of dangerous situation. Why was this a risk to client? Was client a risk to others?
Response: Describe provider response to situation
Dangerous Situation Type: (choose all that apply)
□ Arson
□ Building rendered inhabitable
□ Client as aggressor/perpetrator
□ Explosion
□ Fire
□ Flood / □ Hostage/Kidnapping
□ Injury to staff by client
□ Loss of Home (disaster)
□ Significant property damage
□ Runaway (only report if client is missing more than 4 hrs)
Others: ______
Emergency Services Involved: (choose all the apply)
□ Ambulance/paramedics
□ Crisis Outreach
□ ER Services
□ Fire Department / □ Law Enforcement
□ Warden Services
□ No Emergency Services Involved
Other ______
Death of a client
Summary of event: Summary of known details. Report death of client even if death occurs outside of the provision of services.
Death due to: / □ Illness
□ Completed suicide
□ Accident / □ Suspected abuse/neglect?
□Homicide
Other: ______
Medication Errors
Type:
□ Wrong Medication
□ Omission
□ Wrong dose administered
□ Wrong method of administration
□ Wrong time (>1 hr variance)
Other: ______/ Reason:
□ Administration error
□ Supply exhausted
□ Staff forgot
□ Prescription unfilled
□ Incorrect chart entry
□ Forgot to send with client
□ Not administered during home visit
Administered by/staff name:
Name of drugs:
Treatment requested as result of error? Yes or No / Treatment location:
□ ED
□ Outpatient
□ Emergency intervention on site
Prescriber contacted? Yes or No / Date prescriber contacted:
Instruction given by prescriber:
Restraints
Note: A restraint event ends when client returns to program/milieu. If a youth is restrained and released, then restrained soon after without returning to milieu, that is one event.)
Describe antecedent/what happened prior to restraint?
Describe nonphysical intervention tried first:
Describe physical intervention employed:
Describe follow up/debriefing with client and/or parent, if applicable:
Describe debriefing with staff, any changes to the plan moving forward? Were new antecedents/triggers discovered?
If client and/or staff were injured, describe injuries:
Restraint Model:
□ Safety-Care
□ TCI
Other: ______/ Restraint Type
□ Physical Restraint
□ Isolation
# of staff involved ______/ Name of staff involved:
1.
2.
3.
4.
5.
Who authorized/approved restraint (longer than 30 minutes) ______
Was there injury to the client? Yes or No / Did the client require treatment? Yes or No
Was there injury to staff? Yes or No / Did staff require treatment? Yes or No
Rights Violation
Summary of Event: How were the youth’s rights violated?
Response: Describe provider response to situation? Debriefing with youth? Guardian notified/involved?
Type of Rights Violations
(Check all that apply)
□ Behavior modifications
□ Communication
□ Confidentiality (HIPPA)
□ Discipline
□ Humane Treatment / □ Medical Care
□ Nutrition
□ Physical Restraint
□ Personal property
□ Physical Exercise / □ Religious Practice
□ Social Activity
□ Voting (18-21 yo)
□ Work
□ Record
□ Seclusion
Serious Injury to Client
Summary of Event: Describe any harm that required emergency services (key words are “emergency services”). Describe type of injury and what caused injury. Only report events that occur during the provision of services.
Response: Describe provider response to situation. What treatment was received and where?
Type of injury:
□ Lacerations requiring stitched/staples
□ Bone fracture/break
□ Joint dislocation
□ Head injury
□ Serious burn
□ Skin wound
Other ______/ Cause of Injury:
□ Fall
□ Accident
□ Seizure
□ Medical Condition
□ Treatment error / □ Origin unknown
□ Quality of care
□ Near drowning
Other: ______
Where did person receive treatment:
□ ER
□ Admitted to hospital / □ Intervention on site
□ Primary Care / □ Urgent Care
Other: ______
Suicide
Note: Report all serious and completed suicides, even if it occurs outside of the provision of services. Do not report Verbal or Gestural Threats
Summary of Event: What happened? Method? Youth’s history with suicide attempts, if known. What mental health service is/was youth receiving?
Response: Describe provider response to situation. Brief assessment summary. Type/location of treatment.
Serious Attempt Yes or No / Completed suicide Yes or No
Treatment Location:
□ Admitted to psych hospital
□ Admit to medical hospital
□ Crisis Assessment / □ Physician’s Office
□ CSU
Internal Use Only Internal Use Only Internal Use Only
Inappropriate Submission: Yes
Reviewed No Further Follow Up: Yes / Date Reviewed ______
Reviewer:
□ Jennifer Dondero, Children’s Clinical Team Leader
□ Jodi Charron, Residential Coordinator
□ Lana Pelletier, Reportable Event Coordinator

12-1-2017

1