How to complete the Incident Report

What should be included in the Incident Report?

Type of Report:

• Initial Written
  • This is our first notification of the incident.  The Date/Time line is the Date and Time you are submitting the report. 
    • This may not be the same date of the Incident.
• Follow-Up
  • There won’t always be a follow up report.  If you find out more information after the initial, but still do not know the outcome of the situation, i.e. How is the member being kept safe; Accident with injury and member is still in the hospital; etc.
• Final
  • There will always be a final report completed.  This is done when you know the final outcome for the member.

Provider must make sure that “Empower” is checked.  That way, when DHS reviews the report, they will know in which PASSE the member is enrolled.

• Make sure the Incident Date and Incident Time are completed with the date/time the Incident occurred. 
  • This is not when you were notified of the incident, it is the actual date of incident
• Complete the Injured Person’s Name
  • This should be our member’s name and information
• The Address is the address of member.
• Phone Number(s) is the contact number for the member (This might be the Guardian/POA number)
• Date of Birth and Age should be completed
• Gender and Race should be completed
• Legal Status should be completed
• Medicaid number and Member ID# should be completed

This should be completed as specifically as possible. 

• Death; Suspected Cause
  • If this is a death check the box and complete the blank with the cause of death.  If unknown, document “unknown”
• Maltreatment/Abuse/Exploitation:
  • Neglect, Verbal, Physical, Sexual
  • Other; This could be Abandonment, Misappropriation of Property, Psychological or Emotional abuse or Exploitation
• Missing Client, Injury, Disturbance, Property Destruction, Theft, Arrest
• Other
  • Try to use this description only when no other fits.
  • If you have questions about where the incident fits, feel free to reach out to the Incident Reporting Team.

Does Incident/Injury Require Medical Attention? 

• Make sure the appropriate answer is checked
• If Medical Attention was required, complete the Physician/Hospital Name with address (at least the facility name and location) of Physician and/or hospital and phone number.

• Make sure one box is checked. 
• If it is other, place a description in the line indicated.

Roles with Relationship to Member and the Names of Others Involved

• This would be anyone who witnessed the incident
• The Guardian, staff members, etc.
• Make sure to include an Address and Phone number for anyone involved.

This section is important for investigations and interviews of witnesses

If there are more than two people involved list the rest in Additional Information As Needed Section

Make sure and check the box of who you notified with the date and time included.

You may want to complete this section last, so that you can put the time you sent to DHS PASSE Incident Reporting in accurately.

• If it is an Adult, you will still need to call the APS Hotline document date and time and case number if given one.
• If it is a Child, you will need to contact the Child Abuse Hotline, document the date, time and case number if given one.
• If Next of Kin or Responsible party needs to be completed do so.  If not document “Unknown in the blanks”
• If Law Enforcement is involved, document the name of the Police Department, the officer involved and Telephone number for investigative purposes.
• Other
  • List any other Notifications made

Page 2

• Complete the report type at the top of page 2
• Document the Date of Incident/Time of Incident/Place of Incident at the top of Page 2

Give a detailed description of the Incident.

Make sure to answer the following:

• Who?
• What?
• When?
• Where?
• Why?

If you got the description/notification secondhand, document who told you about the incident and when you were notified.  This starts the timeline for reporting to DHS.

Please mark Yes or No on whether the incident could have been prevented.

• If you mark yes, you must document in the box on how the incident could have been prevented.
• If you mark no, document “N/A” in the box

• This box should be checked as “Pending Investigation” if this is an Initial or Follow up report.
• If this is a Final Report, “Investigated with Appropriate Action/Preventive Plan Attached should be checked.

Document in the “Additional Information as Needed” with how you followed up with the member, ensured member safety, updated PCSP, etc.

• Document your Name and Title
• Document Empower as the PASSE with your phone number and email address
• Document the HCBS Provider and Contact with a phone number and email address.
• If you don’t know this information, try to locate it or put unknown.
• If unknown, document the location of the HCBS Provider.
• The email address at the bottom of page 2 is the email address for DHS submission.

Before sending, make sure to go back and put the date and time for DHS submission in the Notifications section.
We are here to Support you in your Incident Reporting Process!  We will work to strive to keep our members safe and healthy on their journeys to better outcomes.

Feel free to reach out to us at any time. 

Jennifer Garrison jennifer.garrison@empowerarkansas.com (501) 516-3624

Precious Thrower [email protected] (501) 813-7881

Sierra Anderson sierra.anderson@empowerarkansas.com (501) 366-4952