Nhtd/sri Form 3 Home And Community Based Services Medicaid Waiver Nursing Home Transition And Diversion (Nhtd)

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New York State Department of Health
Division of Home and Community Based Services
SERIOUS REPORTABLE INCIDENT
QUALITY MANAGEMENT SPECIALIST
INITIAL RESPONSE
HOME AND COMMUNITY BASED SERVICES MEDICAID WAIVER
Nursing Home Transition and Diversion (NHTD)
An allegation of a Serious Reportable Incident involving
Participant Name:
CIN:
was reported on:________________ by:
Date
Discoverer
The incident number for this Serious Reportable Incident is: __________-_________-_________-__________
This incident has been originally classified as:
Category(s) of Incident
Select one (A, B or C):
A.
QMS agrees with original classification of this incident.
B.
QMS does not agree with original classification of the incident and has re-classified the incident to:
Abuse and Neglect
(select type):
1.
Physical Abuse
Sexual Abuse
Psychological Abuse
Seclusion
Use of Aversive Conditioning
Violation of Civil Rights
Mistreatment
Neglect
Exploitation
Missing Person
Restraint
2. Missing Person
3. Restraint
4. Death
5. Hospitalization
6. Possible Criminal Act
7. Medication Error/Refusal
8. Medical Treatment
9. Sensitive Situation
Due to Accident/Injury
C.
QMS has re-categorized this Serious Reportable Incident to a Recordable Incident status.
NOTE: QMS must also complete the QMS “Status Report” form and ‘Close’ this investigation.
The investigation has been assigned on:
/
/
to:
Date
Provider Agency
located at:
Address
QMS Comments:
A Follow-Up Report is due:
within seven (7) calendar days of the date of this report: (Date Due)
and
within thirty (30) calendar days of the date of this report: (Date Due)
QMS Comments:
QMS Name
Signature
Date
Copy sent to: Reporting Provider Agency (date)
Investigating Provider Agency (date)
Regional Resource Development Specialist (date)
Service Coordinator (date)
FOR QMS USE ONLY:
Form Sent to DOH WMS
Date: _____/_____/_____
NHTD/SRI Form 3
Page 1 of 1
April 2008

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