Critical Incident Report User Guide Form 470-4698 - Iowa Medicaid ...

Iowa Department of Human ServicesIMPA Incident Reporting FormIMPA Users Guide – Revised May, 2010• HCBS WAIVER CHILDREN’S MENTAL HEALTH: - The CMH waiver provides services for children who have been diagnosedwith a serious emotional disturbance.• STATE PLAN HABILITATION: - Habilitation Services are designed to assist participants with chronic mental illness inacquiring, retaining and improving the self-help, socialization and adaptive skills necessary to reside successfully in homeand community-based settings.• GRANTS MFP: - The Money Follows the Person grant is utilized to expand services beyond what is currently offered underthe Intellectually Disabled and Brain Injury waivers to provide services to individuals transitioning into the community fromICF/MR’s.Figure 3: Incident Information, Part 1 Initial ReportThe INCIDENT INFORMATION section of the Initial Report collects information on the location, conditions, andinvolved individuals, as well as a short narrative, on the circumstances surrounding the incident.Figure 4: Date & Time of Incident, Part 1 Initial ReportFields in the Incident Information section of the Initial Report include information on the date and time of the incident:DATE AND TIME OF INCIDENT: - Enter the date and time that the incident was observed or discovered. Select either AMor PM.DISCOVERED: - Select this checkbox if the staff person discovers, or is told, of an incident but was not present,was not involved, or where the incident is suspected.Page 8