OADS - LTSS Event Form.pdf
PDF 147 KB Posted
- Solicitation number
- RFP - 10A - 202605096
- Issued by
- Maine
About this file
OADS - LTSS Event Form Summary
This document is an incident reporting form developed by the Office of Aging and Disability Services (OADS) in Maine for the Long-Term Services and Supports (LTSS) program. The form functions as a standardized reporting mechanism for agencies and providers to document and report critical events affecting program participants within 24 hours of notification. The form captures comprehensive incident information across multiple service programs, including Private Duty Nursing, Home Based Supports and Services, HCBS Elder and Disabled Adults Waiver, Consumer Directed Attended Services, Consumer Directed Assistance Program, Independent Support Services, Adult Day Program, and OADS Assisted Housing. The form requires detailed participant identification, event classification, reporter information, notification status of family and guardians, and documentation of circumstances surrounding reportable incidents.
The form encompasses a broad spectrum of reportable events including medical treatment beyond first aid, abuse allegations (emotional, physical, sexual, verbal), neglect (self-neglect, deprivation of essential needs, caregiver neglect), medication errors, suicide threats or attempts, missing participants, law enforcement intervention, emergency restraint usage, rights violations, and dangerous situations posing imminent risk of harm. For incidents involving abuse or neglect, the form requires detailed classification of the alleged violation type, identification of the alleged perpetrator and their relationship to the participant, agency affiliation, and whether Adult Protective Services (APS) referrals were made. Additionally, the form documents medical treatment outcomes, hospitalization status within 30-day windows, and any resulting additional care needs, ensuring comprehensive incident tracking and quality management oversight within Maine's LTSS programs.
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Other files
| File | Type | Posted |
|---|---|---|
| RFP 202605096 Q | — | |
| RFP 202605096 QIO Quality Mngmt and Support-FINAL.docx | DOCX document | |
| OADS - Evergreen Reportable Event Form.pdf | ||
| QIO Proposed Services Response Form.docx | DOCX document | |
| RFP 202606104 Public School Electronic Health Record_FINAL.docx | DOCX document | |
| QIO Cost Proposal Template toDHHS.xlsx | XLSX spreadsheet |
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Text version
OADS - LTSS Event Form
All reports must be filed within 24 hours from notification of event
* Required
1. Are you reporting a death? *
Yes
No
2. Date of notification (When was your agency informed of event?) *
3. Stop. Do not submit event form.
Please close this form and complete "Death Report Form" https://forms.office.com/Pages/ResponsePage.aspx?id=q6g_QX0gYkubzeoajy- GToeqBeBXbQdKkeFxG90dxilUNUZNNzI2RTdSWVY1WVcxWUtMQVBNUE9PWS4u https://forms.office.com/Pages/ResponsePage.aspx?id=q6g_QX0gYkubzeoajy-GToeqBeBXbQdKkeFxG90dxilUNUZNNzI2RTdSWVY1WVcxWUtMQVBNUE9PWS4u https://forms.office.com/Pages/ResponsePage.aspx?id=q6g_QX0gYkubzeoajy-GToeqBeBXbQdKkeFxG90dxilUNUZNNzI2RTdSWVY1WVcxWUtMQVBNUE9PWS4u https://forms.office.com/Pages/ResponsePage.aspx?id=q6g_QX0gYkubzeoajy-GToeqBeBXbQdKkeFxG90dxilUNUZNNzI2RTdSWVY1WVcxWUtMQVBNUE9PWS4u
4. Reporter ID (Who informed you of the event?) *
Participant
Family member
Advocate
Community provider
Legislative, Commissioners, etc.
Governor's office
Direct care provider
OADS
Alpha One
Assessing services agency
MaineCare
SeniorsPlus
OFI
ISS provider
Facility
CareLync Maine
Other
5. Reporter's first and last name (Who told you about the event) *
6. What is the participant's first name? *
7. What is the participant's last name? *
8. What is the participant's Social Security number? (Format: XXX-XX-XXXX) *
9. What is the participant's MaineCare ID? (Enter "0" if participant has never applied and has no
ID number) *
10. Zip code of participant's residence? *
The value must be a number
11. Program *
Private Duty Nursing Section 96
Home Based Supports and Services 63
HCBS Elder and Disabled Adults Waiver Section 19
Consumer Directed Attended Services Section 12
Consumer Directed Assistance Program- Chapter 11
Independent Support Services - Section 69
Adult Day Program- Section 61
OADS Assisted Housing- State Funded ALF/IHSP
Homeward Bound
12. Self-directed? *
13. Event start date (When did event happen?) *
14. Location of event *
Participant's home
Hospital
Community
Nursing facility
Adult day care
15. Participant's family notified *
No family
16. Guardian notified *
No guardian
17. Who notified guardian? (First and last name of person) *
18. Event type (Select one) *
Medical treatment beyond first aid
Abuse
Neglect
Exploitation
Medication error (Report medication errors only if leading to a health or safety concern of a serious and immediate nature)
Suicide acts, attempts, threats
Lost or missing participant
Physical plant disaster
Law enforcement intervention
Physical assault/altercation (Initiated by participant)
Emergency restraint (Applies to participants with IDD, Autism and Brain Injury only)
Rights violation (Applies to participants with IDD, Autism and Brain Injury only)
Dangerous situation (Event posing an imminent risk of harm to participant or others not otherwise included on this form)
19. Abuse includes actions which result in bodily harm, pain or mental distress.
Examples of abuse are: pushing, hitting shaking, pulling hair, giving the wrong medication on purpose, tying to a bed or chair or locking in a room; denying visits with friends or family and name calling, harassment and verbal threats.
Type of abuse alleged: *
Emotional abuse
Physical abuse
Cruel punishment
Intimidation
Unreasonable confinement
Verbal abuse
Sexual abuse
20. Type of sexual abuse *
Allegations of non-consensual sexual activity
Allegations of sexual contact with incompetent participant
Allegations of contact between paid provider and participant (includes consensual sexual activity)
21. Neglect is a failure to provide care and services when an adult is unable to care for themselves.
Neglect may be at the hands of someone else or it may be self neglect.
Neglect includes failure to provide: adequate shelter, clothes or food; personal care, medical attention or necessary medicine or other necessities such as: glasses, walker, dentures, hearing aids. *
Self neglect
Deprivation of essential needs
Caregiver neglect
Safety issues/risks
Inability to give informed consent
Lack of adequate protection
Caregiver under influence
22. Choose medication error type
(Specify medication in notes) *
Administration error
Medication unavailable
Participant/natural support forgot
Non-compliance
23. Medications are administered/set up by *
Participant
Family member/natural support
Provider sets up and administers
Provider set up only
Provider admin only
24. First and last name of alleged perpetrator (responsible party) *
25. Relation to participant *
Direct care staff
Nurse
Family
26. Agency name (Employer of involved staff)
Specify "Independent RN" if applicable Specify the applicable FI if consumer self-directs *
27. Participant indicates a present intention and a plan to end life; participant attempted to end life *
Suicidal threats
Suicide attempt
28. Was treatment provided as a result of this event? *
Unknown
29. Medical treatment was a result of *
Serious injury
Exacerbation
New medical condition
30. Type of injury *
Laceration requiring suture
Serious burn
Fracture
Skin wound due to poor care
Dislocation
Loss of limb
31. Exacerbation of *
32. New medical condition *
Fall (If fall resulted in fracture, report as "serious injury")
Poor care (E.g. skin wounds)
Accident
Seizure
Medical condition
Treatment error
33. Treatment provided *
Hospitalization
Emergency room
Urgent care
Physician office
Outpatient mental health
Crisis intervention
EMS
34. Was the participant hospitalized or seen in the ER for the same condition within the past 30 days? *
35. Does lost/missing participant have: *
Cognitive impairment
Mental health concerns
No cognitive/mental health concerns
36. Authorities notified/ involved? *
Police
Game warden
37. Participant has been displaced from their residence due to the condition of their home as a result of the following physical plant disaster: *
Fire
Natural disaster
38. Law enforcement intervention involving any of the following *
A participant is charged with a crime or is the subject of a police investigation
A participant is a victim of a crime and law enforcement has been contacted regarding the crime
Law enforcement personnel have been contacted as a result of planned strategy or unplanned crisis situation
39. Use of emergency restraint (Not part of an approved behavior plan pursuant to 14-197
C.M.R. Ch.5) on an individual receiving services
Specify type of restraint: *
Physical restraint
Chemical restraint
40. Did this result in any additional care needs *
41. Was a referral to APS made *
42. Date APS referral made
| OADS - LTSS Event Form |
| 1. Are you reporting a death? * |
| 2. Date of notification (When was your agency informed of event?) * |
| 3. Stop. Do not submit event form. |
| 4. Reporter ID (Who informed you of the event?) * |
| 5. Reporter's first and last name (Who told you about the event) * |
| 6. What is the participant's first name? * |
| 7. What is the participant's last name? * |
| 8. What is the participant's Social Security number? (Format: XXX-XX-XXXX) * |
| 9. What is the participant's MaineCare ID? (Enter "0" if participant has never applied and has no ID number) * |
| 10. Zip code of participant's residence? * |
| 11. Program * |
| 12. Self-directed? * |
| 13. Event start date (When did event happen?) * |
| 14. Location of event * |
| 15. Participant's family notified * |
| 16. Guardian notified * |
| 17. Who notified guardian? (First and last name of person) * |
| 18. Event type (Select one) * |
| 20. Type of sexual abuse * |
| 22. Choose medication error type (Specify medication in notes) * |
| 23. Medications are administered/set up by * |
| 24. First and last name of alleged perpetrator (responsible party) * |
| 25. Relation to participant * |
| 27. Participant indicates a present intention and a plan to end life; participant attempted to end life * |
| 28. Was treatment provided as a result of this event? * |
| 29. Medical treatment was a result of * |
| 30. Type of injury * |
| 31. Exacerbation of * |
| 32. New medical condition * |
| 33. Treatment provided * |
| 34. Was the participant hospitalized or seen in the ER for the same condition within the past 30 days? * |
| 35. Does lost/missing participant have: * |
| 36. Authorities notified/ involved? * |
| 37. Participant has been displaced from their residence due to the condition of their home as a result of the following physical plant disaster: * |
| 38. Law enforcement intervention involving any of the following * |
| 39. Use of emergency restraint (Not part of an approved behavior plan pursuant to 14-197 C.M.R. Ch.5) on an individual receiving services |
| 40. Did this result in any additional care needs * |
| 41. Was a referral to APS made * |
| 42. Date APS referral made |
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