Self-Report/Facility Reporting Requirements
PDF Version of OQA 06-030
(PDF 34 KB)
Date: November 30, 2006 -- OQA Memo 06-030
To: Adult
Family Homes AFH 12
Community
Based Residential Facilities CBRF 14
Residential
Care Apartment Complexes RCAC 10
From: Kevin Coughlin, Chief Assisted Living Section
Via: Otis Woods, Director, Office of Quality
Assurance
Self-Report/Facility Reporting Requirements
PURPOSE
The purpose of this memo is to serve as a reference for Adult Family
Homes (AFHs), Community-based Residential Facilities (CBRFs), and
Residential Care Apartment Complexes (RCACs) on the types of incidents
that need to be reported to the Office of Quality Assurance (OQA). These
reports, known as self-reports, are required to be submitted to the
Department under Wisconsin Statutes, ch. 50, and Wis. Administrative Code,
chs. HFS 83, 88, and 13. Providers may also self-report incidents or
situations not required by regulation.
REPORTABLE INCIDENTS BY PROVIDER TYPE
AFH
1. According to § HFS 88.03(5), licensees of AFHs must report to
OQA
the following incidents within the time
specified:
a. Report within seven days any
significant and ongoing change in the
type or amount of
services the licensee offers to provide, if the
change adversely
affects any resident who needs the service.
b. Report within seven days any change
in household members,
excluding paid
staff, i.e., any person who is not a resident but lives
in the AFH.
c. Report within 48 hours that the
licensee or service provider has
pending, has been
charged with, or convicted of any crime that is
substantially
related to caring for dependent persons.
d. Report within seven days any change
in the home's structure or
damages to the home
that may present a hazard to the residents.
e. (1) Report within 24 hours, any
significant change in a resident's
status, such as,
but not limited to, an accident requiring
hospitalization,
elopement from the home, or a reportable death. A
death shall be
reported if there is reasonable cause to believe that
the death was due
to use of a physical restraint or psychotropic
medication, was a
suicide, or was accidental.
(2) Report
within three days any death due to incident or accident
not due to use of a
restraint, psychotropic medication, or suicide.
2. According to § HFS 88.11, an AFH provider who knows, or has
reasonable cause to suspect, that a resident has
been abused or
neglected as defined in Wis. Stats. §§ 46.90 or
940.285, shall
immediately, i.e., without delay, contact the
licensing agency.
Self-reports are to be sent to the regional office that serves the
facility. Providers will not receive confirmation from the Department of
receipt of a self-report. Once a self-report is received, the Assisted
Living Regional Director will review the report and determine what
actions, if any, are required by the Department.
CBRF
1. According to Wis. Stat. § 50.035(5)(b) and § HFS 83.19(2), a
CBR
must report to OQA the following incidents within
the time specified:
a. Report within 24 hours after the
death of a resident, if there is
reasonable cause to
believe the death was related to the use of a
physical restraint
or psychotropic medication or was a suicide.
b. Report to OQC within three working
days, when a resident dies as
a result of an
incident or accident not related to the use of a
physical restraint
or psychotropic medication, and the death was
not a suicide.
2. According to § HFS 83.19(3), a CBRF must send a report to the
Department within three (3) working days
after any of the following
incidents occurs:
a. A fire on the premises of the CBRF.
b. When the licensee, administrator,
employee or a resident contract
a communicable
disease required to be reported under Wis.
Admin. Code, ch.
HFS 145.
c. When a resident's whereabouts is
unknown and he or she is
considered missing,
and the resident is considered to be in
danger. The local
law enforcement authority shall be notified as
soon as this
determination is made. The CBRF shall notify OQA
within three (3)
calendar days after notification of the law
enforcement
authority. This subdivision does not apply to CBRFs
serving clients of
a governmental corrections agency or persons
recovering from
substance abuse.
d. At any time the police are called to
the CBRF as a result of actions
or incidents that
seriously jeopardize the health, safety, or welfare
of residents or
staff. A description of the circumstances that
required police
intervention shall be provided to the OQA. This
subdivision does
not apply to CBRFs serving clients of a
governmental
corrections agency.
e. When an accident occurs resulting in
a serious injury requiring
inpatient
hospitalization of a resident.
f. When a catastrophe occurs
resulting in damage to the CBRF.
Self-reports are to be sent to the regional office that serves the
facility. Providers will generally not receive confirmation from the
Department of receipt of a self-report. Once a self report is received,
the Assisted Living Regional Director will review the report and determine
what actions, if any, are required by the Department.
AFHs, CBRFs, and RCACs
1. All assisted living providers regulated by the OQA, except
Adult Day
Care providers, must report incidents of
caregiver misconduct as
defined under Wis. Admin. Code, ch. HFS 13, if
the incident meets
the reporting requirements.
2. Providers must conduct a complete and thorough investigation
of
allegations of caregiver misconduct (abuse,
neglect, misappropriation
of property) and injuries of unknown source. The
provider must report
an incident, i.e., caregiver misconduct or
injuries of unknown source, if
both of the following conditions are true:
a. There is a reasonable cause to
believe they have sufficient
evidence, or
another regulatory authority could obtain the
evidence, to show
the alleged incident occurred; AND
b. There is reasonable cause to believe
that the incident meets, or
could meet, the
definition of abuse, neglect, or misappropriation.
3. If the conclusion is that you must report the incident, then
complete the
Incident Report of Caregiver Misconduct Form
(DDE-2447). Submit
reports of alleged caregiver misconduct and
injuries of unknown
source within seven (7) calendar days of the
incident or the date the
entity knew of the incident. Submit the completed
DDE-2447 Incident
Report for allegations involving all staff
(including credentialed and
non-credentialed) to:
OFFICE OF CAREGIVER QUALITY
2917 INTERNATIONAL LN, STE 300
MADISON WI 53704-3100
NOTE: In the past, providers were required to submit the report either
to OQA or to the Department of Regulation and Licensing (DRL). This
process has been streamlined to eliminate reporting to two different state
agencies. All caregiver misconduct reports are now submitted to OCQ staff,
who will forward those reports involving credentialed staff (e,g., MDs,
RNs, LPNs, Social Workers, etc.) to DRL for review.
Reference: BQA Memo 04-028
Revised Caregiver Misconduct Reporting Requirements
for BQA Entities
ASSISTED LIVING REGIONAL OFFICES
Northern Region
Assisted Living Regional Director
2187 N STEVENS ST STE C
RHINELANDER WI 54501-8036
Phone: (715) 365-2816
Fax: (715) 365-2815
Northeastern Region
Assisted Living Regional Director
200 N JEFFERSON ST STE 211
GREEN BAY WI 54301-5100
Phone: (920) 448-5338
Fax: (920) 448-5254
Southeastern Region
Assisted Living Regional Director
819 N 6TH ST RM 609-B
MILWAUKEE WI 53203-1606
Phone: (414) 227-4565
Fax: (414) 227-3903
Southern Region
Assisted Living Regional Director
2917 INTERNATIONAL LN STE 300
MADISON WI 53704-3100
Phone: (608) 243-3868
Fax: (608) 243-2389
Western Region
Assisted Living Regional Director
610 GIBSON ST STE 1
EAU CLAIRE WI 54701-2626
Phone: (715) 836-4029
Fax: (715) 836-2535
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