Iowa Medicaid Critical Incident Report Page 3
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IOWA MEDICAID CRITICAL INCIDENT REPORT
Incident-specific Resolutions
Staff
(Please note: Complete the Staff Review section only if staff issues contributed to the incident.)
Review
Review staff:
(select all that apply)
Provide
staff training on: (select all that apply)
rights
increase
number of staff
disciplinary action
individual needs
increase staff hour
change staff
behavioral needs
improve team building
terminate staff
positive and supportive relationships
increase supervision of staff
other, describe:
communication with member, family and/or other staff
_________________________
staff trained / retrained on equipment use
other, describe: _____________________________________
Resolution following staffing review / training. Describe specifically how action(s) will prevent or diminish the probability of future
occurrence(s)._______________________________________________________________________________________________________
No staffing changes required. Describe how this adverse incident was isolated with a minimal probability of a reoccurrence.
_________________________________________________________________________________________________________________
(Please note: Complete the Member Review section only if member issues contributed to the incident.)
Member
Review member:
(select all that apply)
Review
treatment plan reviewed and/or revised due to behavioral issues
treatment plan reviewed and/or revised to reflect member’s goals
treatment plan reviewed and/or revised due to cognitive abilities
treatment plan reviewed and/or revised due to communication needs
treatment plan reviewed and/or revised due to physical abilities
treatment plan reviewed and/or revised due to level of need and support
treatment plan reviewed and/or revised due to medical / health status, including medication review
treatment plan reviewed and/or revised due to unidentified risk or safety issues; safety plan reviewed / modified
___________________________________________________________________________
other, describe:
Resolution following member review. Describe specifically how revision(s) will prevent or diminish the probability of future occurrence(s).
_________________________________________________________________________________________________________________
Treatment plan reviewed and no changes required. Describe how this adverse incident was isolated with a minimal probability of a
reoccurrence. ______________________________________________________________________________________________________
(Please note: Complete the Equipment & Supplies Review section only if their presence, absence and/or condition contributed to the
Equip &
incident.)
Supplies
Review of equipment and / or supplies:
(select all that apply)
Review
necessary equipment needs to be repaired
necessary
equipment needs to be replaced
necessary equipment needs to be purchased
other, describe _____________________________________________________
Resolution following equipment and supplies review. Describe specifically how this review(s) will prevent or diminish the probability of
future occurrence(s). ________________________________________________________________________________________________
Equipment and supplies reviewed and no changes required. Describe how this adverse incident was isolated with a minimal probability of
a reoccurrence. ____________________________________________________________________________________________________
(Please note: Complete the Environment Review section only if the identified condition or circumstance contributed to the incident.)
Environ
Review
Review of environment:
(select all that apply)
member’s physical environment evaluated, and modified if necessary, for safety issues
member’s physical environment evaluated, and modified if necessary, to increase accessibility
member’s interpersonal relationships within their environment evaluated, and accommodated / modified if necessary, for safety reasons
other, describe__________________________________________________________________________________________________
Resolution following environmental review. Describe specifically how action(s) will prevent or diminish the probability of future
occurrence(s)._______________________________________________________________________________________________________
Environment reviewed and no changes required. Describe how this adverse incident was isolated with a minimal probability of a
reoccurrence. ______________________________________________________________________________________________________
470-4698 (Rev 5/10)
(MAIL) Provider Correspondence, PO Box 36450, Des Moines, IA 50315 (FAX) 515-725-1360
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Parent category: Medical