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North Carolina Department of Health & Human Services – Division of Mental Health/Developmental Disabilities/Substance Abuse Services

DHHS Incident and Death Report

CONFIDENTIAL

Provider Agency Name

Consumer’s Name

LME Client Record Number.

This form is used to report Level II and Level III incidents, including deaths and restrictive interventions, involving any person receiving publicly funded mental health, developmental

disabilities and/or substance abuse (MH/DD/SA) services. Facilities licensed under G.S. 122C (except hospitals) and unlicensed providers of community-based MH/DD/SA services must

submit the form, as required by North Carolina Administrative Code 10A NCAC 27G .0600, 26C .0300, and 27E .0104(e)(18). Failure to complete this form may result in administrative

actions against the provider’s license and/or authorization to receive public funding. This form may also be used for internal documentation of Level I incidents, if required by provider

policy or LME contract. Effective March 8, 2006, this form replaces the DHHS Incident and Death Report (Form QM02, Revised 11/18/04).

Instructions: Complete and submit this form to the local and/or state agencies responsible for oversight within 72 hours of learning of the

incident (See page 3 for details). Report deaths of consumers that occur within 7 days of restraint or seclusion immediately.

If requested information is unavailable, provide an explanation on the form and report the additional information as soon as possible.

Page 1-2 Instructions: The staff person who is most knowledgeable about the incident should complete pages 1-2 of this form as soon as possible

after learning of the incident and submit to the unit supervisor for review and approval.

a.m.

p.m.

Unknown

Date of Incident

Time of Incident:

Consumer’s Date of Birth:

Consumer’s Gender:

Male

Female

Consumer’s Ethnicity (Check all that apply):

All Diagnoses:

Hispanic/Latino

Native American

Asian/Pacific Islander

Other (specify):

White/Anglo

Black/African American

Does consumer receive CAP/MR-DD Waiver services?

Yes

Unknown

LOCATION OF INCIDENT

OTHER PEOPLE INVOLVED

(Provide the name of the person and his/her relationship to the consumer that is the subject of the

Provider premises

report. Do not provide the name or other identifying information for other consumers in this

section. Instead indicate the number of other consumers who were involved.)

Consumer’s legal residence

Community

Other (specify)

(such as hospital, state

institution, etc.)

Unknown

Name / title of first staff person to learn of incident

Was the consumer under the care of the reporting provider at the time of the incident?

Yes

Was the consumer treated by a licensed health care professional for the incident?

Yes

Date:

Was the consumer hospitalized for the incident?

Yes

Date:

Describe the incident, including Who, What, When, Where, and How. (Describe any preceding

INJURY

circumstances, resulting harm to people, property damage, and any other relevant information. Attach

On the figures below, circle the

additional pages if needed. Do not provide another consumer’s name or identifying information here.)

location of any bruises, cuts,

scratches, injuries, or other marks that

occurred as a result of the incident.

FRONT

BACK

NOTE: Incident reports are confidential quality assurance documents, protected by GS 122C-30, 122C-31, 122C-191 and 122C-192. Do not file incident reports in the

consumer’s service record. Confidentiality of consumer information is protected under Federal regulations, 42 CFR Part 2 and HIPAA, 45 CFR Parts 160 and 164.

DMH/DD/SAS-Community Policy Management Section – Form QM02

Effective October, 2004 - Rev. 3/8/06

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