Nevada DHCFP Serious Occurrence Report Form

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MEDICAID FORM RELEASE MEMO

TO: FRM Distribution FRM Number: NMO-3430A

Issue Date:

FROM: Publications Control Effective Date: Upon Receipt

SUBJECT: Nevada DHCFP Serious Occurrence Report Form A

The following is for your information and action. Attached please find the new or revised form to be

used. The actual form may vary in size, color, type of paper or printing method. Please update your

FRM log and Forms Manual.

NEW FORM/BULLETIN

REVISED FORM: Destroy old version after new stock is received.

SUPPLY is being sent to all using offices.

REVISED FORM: Use old version until supply is exhausted.

Revised FORMS CONTROL INDEX

SUPERSEDED: Form/date , FRM

OBSOLETE: Form/date , FRM ____________

PURPOSE:

The Original form, NMO-3430-E has been split into two independent forms. One for an individual to

report serious occurrences (now known as form NMO-3430A) and one for state case managers to

complete when following up on a reported serious occurrence (form NMO-3430B). The purpose of

this form, NMO-3430 is to collect objective and factual data regarding identified serious occurrences

and must be completed by any individual who becomes aware of a serious occurrence.

Definition:

1. Serious Occurrence: any actual or alleged event or situation that relates a significant risk of

substantial or serious harm to the safety or well being of a recipient of the above mentioned

programs.

Reportable serious occurrences include:

 Unplanned or unexpected hospitalization

 Injuries requiring medical intervention or injuries of unknown origin;

 Alleged physical abuse, verbal abuse, sexual abuse, or sexual harassment;

 Neglect of the recipient;

 Suicide threat or attempt;

 Criminal activity or legal involvement

 Alleged Exploitation or Theft;

 Medication errors;

 Loss of contact or Elopement

 Any event which is reported to Child and Elder Protective Services or law

enforcement agencies;

 Death;

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 Property damage, auto accident, staff injuries, or environmental concerns; or

 Other occurrences not identified above. .

INSTRUCTIONS:

1. Any person who becomes aware of a serious occurrence must report the occurrence by

completing the serious occurrence report. This includes: Service providers, MFP transition

coordinators, service coordinators, and case managers. One report per incident is required.

Do not use the same form to report multiple incidents; each incident is a separate form. For

example, if a person falls 4 times in one day at different times; four incidents. If a person

falls, sustains injuries, and goes to the hospital; all once incident due to the chain of events

from the fall.

2. The serious occurrence report must be completed and submitted within 24 hours of

discovery by the individual who discovered the event.

3. The form must list only objective data and facts. Do not include opinions in the report. The

form’s function is to relay the honest actual facts of the occurrence. A narrative may be

attached to the form.

4. Providers who initiate serious occurrence reports must retain a copy in the recipient’s chart

or a separate serious occurrence folder and send a copy to the appropriate agency as listed

below.

5. Any person who fills out the form must choose only one event, not multiple events. The

description of the event can include the cause. If there are multiple events, then each event

must have a separate form. For example: If an individual dies as a result of a medication

error, an assault or a suicide attempt; the correct event is death. The cause is the

medication error, assault or suicide attempt. The cause would be captured in the comments

field.

ROUTING THE SERIOUS OCCURRENCE REPORT (see below for fax numbers):

Agency: Select the state agency that the report goes to. Electronic reports will go to a

queue where they will be routed appropriately. This is mandatory for the individual

completing the form. For paper copies, see routing by program and fax numbers below for

agencies.

To Medicaid DHCFP District Office (Local Area) 

 Personal Care Services (PCS) (Non-Waiver)

 Money Follows the Person Grant (MFP)

 Adult Day Health Care Services (ADHD)

To Aging Services (ADSD) (Local Area) 

 Homemaker (HM)

 Home and Community Based Waiver (HCBW) for Physically Disabled (PD)

 HCBW – Frail Elderly (FE) Recipient

 Personal Assistance Services (PAS)

 Community Options Program for the Elderly (COPE)

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To Development Services (DS) (Local Area) 

 HCBW – Intellectual Disabilities

(ID)

 Intermediate Care Facility (ICF)

Development Services (DS) Other

FAX NUMBERS:

 Health Care Financing and Policy Division (Medicaid Agency)

o Carson City: (775) 684-3720

o Elko: (775) 753-1101

o Las Vegas: (702) 668-4280 or (702) 668-4279

o Reno: (775) 687-1901

 Aging and Disability Services Division (ADSD)

o Carson City: (775) 687-4264

o Elko: (775) 753-8543

o Las Vegas: (702) 486-3572

o Reno: (775) 688-2969

 Developmental Services

o Rural Regional Center (RRC)

 Carson City: (775) 684-1001

 Elko: (775) 777-7884

 Fallon: (775) 423-0357

 Silver Springs: (775) 577-9571

 Winnemucca: (775) 623-6594

o Sierra Regional Center (SRC) (775) 688-1947

o Desert Regional Center (DRC) (702) 486-5698

FORM COMPLETION:

1. Agency – Select the agency. Electronic submissions are routed to the appropriate queue;

paper submissions are routed as indicated above.

2. Program – Check the appropriate box indicating the recipient’s program area:. State staff

must verify for accuracy.

 Personal Care Services (PCS) (Non-Waiver)

 Home and Community Based Waiver (HCBW) for Physically Disabled (PD)

 HCBW – Frail Elderly (FE) Recipient

 HCBW – Intellectual Disabilities

(ID)

 Personal Care Services (PCS) (Non-Waiver)

 Intermediate Care Facility (ICF)

 Personal Assistance Services (PAS)

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Homemaker (HM)

 Money Follows the Person Grant (MFP)

 Adult Day Health Care Services (ADHD)

 Community Options Program for the Elderly (COPE)

 Development Services (DS) Other

3. Name – Enter the involved recipient’s last and first name.

4. Recipient’s Nevada Medicaid ID # - Enter the correct 11 digit number

5. Recipient’s Date of Birth – Enter the recipient’s date of birth.

6. Date of Occurrence: Enter the date the occurrence occurred, and where.

7. Provider Agency and Provider API or NPI – Enter the name of the provider agency and the

specific API or NPI related to the recipient and the serious occurrence.

8. Name of person reporting the occurrence/filling out the form:

9. Indicate the relationship of the individual reporting/filling out the form to the recipient.

10. Date of Discovery – Enter date of when the incident was discovered, if not witnessed.

11. Agency or Provider Supervisor – Enter the name of the supervisor or contact person of the

person reporting. This should be the person who may be contacted to answer any further

questions regarding the incident or follow-up.

12. Agency or Provider location: This is required for providers who have multiple locations.

13. Region: Indicate north, south or rural.

FACTUAL DESCRIPTION OF INCIDENT: Check ONLY the box(es) that apply.

Unplanned Hospital/ER Visit

Facility – Enter the name of the hospital or facility the recipient was taken to.

1. Type of Unplanned Hospital or ER visit – Check the appropriate box:

 Reason – Indicate either injury, illness, pain, or psychiatric/behavioral.

Injury or Fall Requiring Medical Intervention OR Injury of Unknown Origin: Must select one or

the other.

1. Type of Injury- Check the appropriate box. It may be necessary to check more than one box.

If checking “Other” enter the type of injury on the narrative line.

 Bruise – A bruise is visible.

 Abrasion/Cut – An abrasion/cut is visible.

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 Facture/dislocation – Suspected - but may not be known until diagnosed at the

hospital/doctor.

 Sprain/strain – Suspected – but may not be known until diagnosed at the

hospital/doctor.

 Swelling/edema – swelling/edema is visible.

 Fall.

 Pain location – where is the pain.

 Skin Tear – a skin tear is visible.

 No visible signs of injury – This is common with falls and stumbles, some can trip, fall

or stumble and not have any of the above injuries. Falls without injury need to be

reported as they can be a sign of a safety risk.

 Other – If something occurs that is not listed above, describe the injury.

2. Person(s) Involved in the Injury- Check the appropriate box. If checking “Other” enter the

relationship of the individual to the recipient. Include the individual’s name if possible.

 Self accident – recipient fell down or unintentionally injured themselves

 Self inflicted – recipient intentionally injured themselves

 Family member – family member intentionally injured recipient

 Roommate – roommate intentionally injured recipient

 Staff member – staff member intentionally injured

 Peer – Another recipient or person living in the same dwelling.

 Other – someone not listed above

 Indicate if the provider or staff was at the residence at the time of the incident

 Indicate whether the fall may have been prevented

Alleged Physical, Verbal, Emotional, Sexual Abuse or Harassment

 Per NRS 200.471, 200.481 and 200.5092, the following definitions are provided to guide the

categorization and description of Assault and Abuse.

 Assault

means intentionally placing another person in reasonable apprehension of

immediate bodily harm.

 Battery means any willful and unlawful use of force or violence upon the person of

another.

 Abuse means any willful and unjustified infliction of pain, injury or mental anguish

upon a client by a person other than another client. This includes, but is not limited

to:

o The rape, sexual assault or sexual exploitation of a client- Examples include

sexual molestation, attempts to engage a client in sexual conduct, sexual

touching or fondling of a client, encouraging a client to sexually touch a staff

member or other client, or himself, exposing one’s sexual parts to a client

and encouraging a client to expose his sexual parts to staff or other clients.

o Striking a client- Also included are any acts which cause physical pain or

injury to the client. Examples include slapping, bruising, pinching, cutting,

burning and unnecessary physical coercion of a client.

o Verbal intimidation or coercion of the client without a redeeming purpose-

This includes actions or utterances that cause mental distress such as

making obscene gestures to the client, name-calling, cursing and words that

frighten, humiliate, intimidate, threaten or insult the client.

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 Per NRS 200.5092 and 433.554 the following definitions are provided to guide the

categorization and description of Neglect.

 Neglect means the failure of a person who has assumed legal responsibility or a

contractual obligation for caring for a person or who has voluntarily assumed

responsibility for his care to provide food, shelter, clothing or services which are

necessary to maintain the physical or mental health of the older person; or a person

to provide for his own needs because of inability to do so.

 Neglect means any omission to act which causes injury to a client or which places

the client at risk of injury, including, but not limited to failure to:

o Follow an appropriate plan of treatment to which the client has consented.

o Follow the policies of the facility for the care and treatment of clients.

1. Type of Alleged Incident – Indicate the type of incident based on the

above definitions.

2. Alleged Victim – Indicate the alleged victim whether it is the recipient,

provider or someone else.

3. Alleged Perpetrator – Indicate the alleged victim whether it is the

recipient, provider or someone else.

Assault, Violence, Threat (by or towards a recipient): Check this box if appropriate and use the

comments field to describe incident.

Suicide Threat with medical or police involvement: Check this box if appropriate and use the

comments field to describe the incident.

Suicide Attempt: Check this box if appropriate and use the comments field to describe incident.

Criminal Activity: Defined as: An act committed or omitted in violation of a law forbidding or

commanding it and for which punishment is imposed upon conviction; an unlawful activity; a serious

offense, especially one in violation of morality; or an unjust, senseless, or disgraceful act or

condition.

Legal Involvement: Personal involvement in some type of legal action or activity where the police are

involved.

Alleged Theft or Exploitation

 Per NRS 200.5092, the following definitions are provided to guide the categorization and

description of Exploitation or Isolation of Older Persons. The definition has been expanded

to include persons of all ages by removing the term “older” in all instances where it

appeared.



Exploitation

means any act taken by a person who has the trust and confidence of

another person or any use of the power of attorney or guardianship of a person to:

o Obtain control, through deception, intimidation or undue influence, over the

other person’s money, assets or property with the intention of permanently

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depriving the other person of the ownership, use, benefit or possession of his

money, assets or property; or

o Convert money, assets or property of the other person with the intention of

permanently depriving the other person of the ownership, use, benefit or

possession of his money, assets or property.



Theft

means taking something, without permission, that does not belong to you

1. Alleged Type - If the incident involved theft, check the box(es) indicating

money and/or property and record the amount of money or specific property

declared to be stolen.

2. Other - Record a description of other assets or act of exploitation if the

incident did not involve theft of money or property.

3. Alleged Perpetrator- Indicate the alleged perpetrator whether it is the

recipient, family member, provider or someone else.

Medication Error

1. Any incident involving medication.

 Wrong Medication – the recipient took or was given the wrong medication

 Wrong Dose – the recipient took or was given an incorrect amount of medication

 Wrong person – the recipient took or was given medication not meantt for them

 Wrong time of Administration – the recipient took or was given medication at the

wrong time

 Skipped Dose – the recipient missed a dose; reason must be indicated.

 Other - any other medication error not listed above. Please explain.

Loss of Contact

1. Loss of contact with the recipient for 3 consecutive days.

Elopement of any recipient residing in a 24 hour setting:

Elopement is defined as leaving a facility such as a nursing home, assisted living facility,

group home or supported living arrangement without notice or prior arrangement.

Elopement/AWOL:

1. Elopement of an recipient from a 24 hour provider.

2. Elopment of a recipient from a non-24 hour provider setting.

3. AWOL – Absent from a setting without permission or knowledge.

Death

1. Death of Recipient or significant caregiver –. Indicate the death of a recipient or significant

caregiver.

2. For Recipient only:

a. Indicate the date of death.

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b. Indicate of death was explained/expected, or unexplained/unexpected.

c. Where the death occurred.

d. Circumstances of death.

e. History of services provided.

f. Cause of death if known.

g. Death certificate or coroner’s report needed/obtained.

h. Any documentation of death must be included in SOR record.

Other Serious Occurrence

1. Other – Record any other activities that are not addressed prior to this point. Types of

incidents include:

a. Provider HIPAA violation

b. Major property damage to recipients living arrange

c. Auto accident involving recipient

d. Staff injury/illness/accident requiring medical attention

e. Environmental incident involving emergency response

f. Other occurrence not indicated which can be anything that is of serious issue to a

recipient.

Action Taken to Protect and Reduce Future Risk

1. EPS/APS/CPS Notified? – Circle entity notified, mark “Yes” or “No” and enter the date

notified.

2. Law Enforcement Notified? – Mark “Yes” or “No” and enter date notified.

3. Guardian/Responsible Person Notified? - Mark “Yes” or “No” and if marking “Yes”, enter the

name and phone number of the person notified.

4. State Staff or Waiver Personnel Notified? - Mark “Yes” or “No” and if marking “Yes”, enter

the name and phone number of the professional.

5. Health Care Quality and Compliance Notified: For providers who are licensed by the State.

6. Comments/details - Additional information if necessary.

Signatures

1. The reporting individual must print and sign their name and include the date the form was

completed.

State Staff Only:

1. Internal use only for after form is sent to state staff.

2. All SOR’s must be reviewed. All HCBW must have follow-up. State plan or state funded

services may or may not require follow up. The follow- up box must be checked for all

SOR’s.

If the SOR is a death, check NA for follow up and use the death follow up questions.

This is there for reporting requirements.

DISTRIBUTION:

This form will be posted on the intranet and the internet for providers to access.

DHCFP Library

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DHCFP District Office

ADSD District Offices and Regional Centers

DHCFP Central Office

HPES