Provider Critical Incident Report Name of Program: Level of Care:

Client Name: DOB:

Incident Date: (month, day, year) Incident Time: AM/PM (circle one)

Names of Staff Involved: (attach additional pages if necessary)

1.

2.

3.

Positions of Staff Involved:

1.

2.

3.

A. Type of Incident:

(Must be reported immediately no more than 2 hours after incident)

☐ Death of client

☐ Attempted suicide by client

☐ Emergency change in placement:

☐ Hospitalization ☐ Incarceration

☐ Absence without leave/Runaway

Date/Time of return:

(Must be reported within 24 hours)

☐ Any serious injury or illness

☐ Suicidal gesture, not life threatening

☐ Prescription medication error

☐ Off-site emergency medical treatment Location:

☐ Off-site emergency medical assessment

Location:

☐ Possession of a weapon

Type:

☐ Possession of an illegal substance

Type:

☐ Removal from school:

☐ Suspension ☐ Expulsion ☐ Homebound

☐ Report/involvement of an outside regulatory agency

Agency:

☐ Placement in seclusion or restraints

☐ Emergency change in placement:

☐ Discharge ☐ Internal Transfer

☐ Attempt to contact prohibited persons and/or contact with person that suggest the potential child/youth has been a victim of sex trafficking

B. Describe the incident and the circumstances surrounding it: (must be legible)

ATTACHMENT C

C. What precipitating factors may have contributed to the incident? (attach additional pages if needed)

D. Describe the behavior management/intervention technique used to de-escalate the client and the client’s response: (attach additional pages if necessary)

E. Describe follow-up actions taken: (attach additional pages if necessary)

F. Notifications:

Role Name/Title of Person Notified Date Time Name of Person Notifying

Internal Staff

Referring Agency

Parent/Guardian

Regulatory Agency

Law Enforcement

Other

Person Completing this Report: Date:

Printed Name Signature Title

Clinical Reviewer: Date:

Printed Name Signature Title

Administrative Reviewer: Date:

Printed Name Signature Title

Instructions for Form ----

Name of Program: Name of organization submitting the incident report. If incident occurred in a CPA foster home, then both the family name and the CPA must be included.

Level of Care: Child’s level of care

Client Name: Child’s full name

DOB: Child’s full date of birth

Incident Date: full date that the incident occurred

Incident Time: time that the incident occurred

Names of Staff Involved: All staff involved and present during the incident, including witnesses, if applicable.

Positions of Staff Involved: Titles of all staff listed as involved.

A. Type of Incident: Mark all that apply. If the selected incident type requests additional information, this information must be provided, i.e. Emergency change in placement, either hospitalization or incarceration must also be selected.

Death of client: self-explanatory

Attempted suicide by client: any suicide attempt that requires any medical treatment

Emergency change in placement:

Hospitalization: if client is admitted to a hospital

Incarceration: if client is arrested and detained

Any serious injury or illness: any injury or illness that requires medical treatment

Suicidal gesture, not life threatening: self-explanatory

Prescription medication error: any medication error made for prescription drugs including, but not limited to, the wrong medication being given, wrong dosage being given, and missed dose of medication

Off-site emergency medical treatment: self-explanatory/provide name of provider where treatment was received

Off-site emergency medical assessment: if client has an injury or illness that requires assessment even if no treatment is prescribed/provide name of provider where client was assessed

Possession of a weapon: self-explanatory

Possession of an illegal substance: possession of any illegal substance included prescription medication not prescribed to that client. Provide specific type of substance the client was in possession of, i.e. “marijuana”, not “drugs”.

Removal from school: self-explanatory

Report/involvement of an outside regulatory agency: any report to or involvement with any regulatory agencies including, but not limited to, OHAN, Law Enforcement, DHEC, and the Office of the Child Advocate.

Placement in seclusion or restraints: self-explanatory

Emergency change in placement: an unplanned discharge or transfer to a different site/home/provider.

B. Describe the incident and the circumstances surrounding it: self-explanatory

C. What precipitating factors may have contributed to the incident: self-explanatory

D. Describe behavior management/intervention technique used to de-escalate the client and the client’s response:

required if the incident involves the client’s behavior.

E. Describe follow-up actions taken: self-explanatory

F. Notifications: self-explanatory

G. A completed copy of this report must be submitted to the referring case manager and SCDSS State Office as soon as practical, but no later than the end of the first business day following the incident.

Person Submitted To Date Submitted Time Submitted Method of Submission

Person Completing this Report: self-explanatory

Clinical Reviewer: name of individual completing a clinical review as required by the contract.

Administrative Reviewer: name of individual completing an administrative review as required by the contract.

G. A copy of the report should be emailed to the case manager and SCDSS State Office at IncidentReport@dss.sc.gov.

Report must be completed in full.

mailto:IncidentReport@dss.sc.gov