Agency Incident Report

ARC HUMAN SERVICES INCIDENT REPORT
Date Of Report*

MonthDayYear
Date
Name of Individual Involved in Incident*
House individual resides at (or other service if applicable)*
Address (1113 6th Ave A)
1113 6th Avenue A, Beaver Falls PA, 15010
Address (1113 6th Ave B)
1113 6th Avenue B, Beaver Falls PA, 15010
Address (1200 4th Ave)
1200 4th Avenue, Beaver Falls PA, 15010
Address (123 Pine St)
123 Pine St, New Brighton PA, 15066-3321 Site Location: 0169
Address (137 Highland Dr)
137 Highland Dr, Beaver Falls PA, 15010-1053 Site Location: 0157
Address (15th Ave)
509 15th Ave, New Brighton PA, 15066-1239 Site Location: 0152
Address (154 Spring Run Road)
154 Spring Run Road, Butler PA, 16001
Address (185 Highland Dr)
185 Highland Dr, Beaver Falls PA, 15010-1052 Site Location: 0193
Address (18th Ave)
1503 18th Ave, Beaver Falls PA, 15010-5345 Site Location: 0146
Address (18th St)
2103 18th St, Beaver Falls PA, 15010-2543 Site Location: 0155
Address (1st St)
452 1st St, Pittsburgh PA, 15227-3893 Site Location: 0092
Address (22 Prigg St)
22 Prigg St Washington PA 15301 Site Location: 0201
Address (28th St)
2405 28th St, Beaver Falls PA, 15010-2343 Site Location: 0143
Address (2nd Ave)
3815 2nd Ave, Beaver Falls PA, 15010-3301 Site Location: 0142
Address (37th St)
3253 37th St EXT, Beaver Falls PA, 15010-1219 Site Location:0144
Address (37th St EXT)
3310 37th St EXT, Beaver Falls PA, 15010-1219 Site Location:0144
Address (4th Ave Beaver Falls)
1200 4th Ave, Beaver Falls, PA 15010-4440 Site Location: 0147
Address (4th Ave New Kensington)
461 4th Ave, New Kensington PA, 15068-6615 Site Location: 0168
Address (580 Fayette)
580 Fayette St, Washington PA, 15301-5517 Site Location: 0007
Address (6th Ave)
813 6th Ave Rear, Beaver Falls PA, 15010-4440 Site Location: 0145
Address (8th Ave)
3301 8th Ave, Beaver Falls PA, 15010-3521 Site Location: 0141
Address (910 East Maiden MH)
910 East Maiden St, Washington PA, 15301-3793 Site Location: 0181
Address (9th Ave New Brighton)
901 9th St Apt 1105, New Brighton PA, 15066 Site Location: 0079
Address (9th Ave Freedom)
1820 9th Ave, Freedom PA, 15042-2019 Site Location: 0153
Address (Allendale)
596 Allendale Rd, New Brighton PA, 15066-3683 Site Location: 0148
Address (Arch)
1158 Arch St, Washington PA, 15301-1930 Site Location: 0090
Address (Arizona)
555 Arizona Dr, New Kensington PA, 15068-3365 Site Location: 0071
Address (Arnold)
111 Arnold Ave, Strabane PA, 15363-9635 Site Location: 0138
Address (Avella)
10 Campbell Dr, Avella PA, 15312 Site Location: 0006
Address (Barnickle)
354 Barnickle St, Meadowlands PA, 15347 Site Location: 0101
Address (Beaver Office)
561 Wallace Run Rd, Beaver Falls PA, 15010-5739 Site Location: 0140
Address (Ben Avon)
215 Alder Dr, Pittsburgh PA, 15202-2107 Site Location: 0057
Address (Brighton Road Ellwood)
2320 Brighton Rd, Ellwood City PA, 16117-3506 Site Location: 0173
Address (Brodhead)
3557 Brodhead Rd, Monaca PA, 15061-3139 Site Location: 0160
Address (Burgley)
544 Burgley Ave New Kensington PA, 15068-2207 Site Location: 073
Address (Carmella)
1600 Carmella Dr, Pittsburgh PA, 15227-3713 Site Location: 098
Address (Charlotte)
431 Charlotte Dr, Pittsburgh PA, 15236-2401 Site Location: 0063
Address (Chess)
375 Chess St, Bridgeville PA, 15017-1981 Site Location: 0088
Address (Circle)
2152 The Circle, Washington PA, 15301-2633 Site Location: 0008
Address (Crandon)
154 Crandon Circle, Beaver PA, 15009-1233 Site Location: 0150
Address (Darlington)
2918 Darlington Rd, Beaver Falls PA, 151010-9601 Site Location: 0161
Address (Deervue)
3969 Deervue Dr, Pittsburgh PA, 15227-4509 Site Location: 0093
Address (Duncan)
530 Duncan Ave, Washington PA, 15301-4145 Site Location: 0089
Address (Dutch Ridge)
3730 Dutch Ridge Rd, Beaver PA, 15009-8557 Site Location: 0162
Address (East College)
171 1/2 E College St, Canonsburg PA, 15317-1730 Site Location: 0011
Address (Elberta)
98 Elberta Dr, Washington PA 15301-2806 Site Location: 0023
Address (Evans Brookville)
66 Evans St, Brookville PA, 15825-1602 Site Location: 0099
Address (Fallowfield)
1429 Fallowfiled Ave, Pittsburgh PA, 15216-3750 Site Location: 0061
Address (Franklin Ave APT 1 427)
427 Franklin Ave APT 1, Canonsburgh PA, 15317-2021 Site Location: 0021
Address (Franklin Ave APT 2 427)
427 Franklin Ave APT 2, Canonsburgh PA, 15317-2021 Site Location: 0195
Address (Hallam)
251 W Hallam Ave, Washington Pa, 15301-4203 Site Location: 0050
Address (Hamilton)
62 Hamilton St, Allenport PA, 15412 Site Location: 0172
Address (Hilltop)
15 Hilltop Ave, Canonsburg PA, 15317-1010 Site Location: 0164
Address (James Place)
57 Jame Place Union Township Brookville Pa 15825
Address (Kendall)
56 Kendall Ave, Pittsburgh PA, 15202-3967 Site Location: 0082
Address (Kenridge)
17 Kenridge Dr, Mckees Rocks PA, 15136-1603 Site Location: 0086
Address (Kilmer)
281 Kilmer Rd, Dubois PA, 15801-6833 Site Location: 0132
Address (Laurel)
47 Laurel Ave, Washington Pa, 15301-3318 Site Location: 0020
Address (Leonard Ave)
85 Leonard Ave APT 205, Washington PA, 15301-3376 Site Location: 0174
Address (Life Sharing - Water Street)
241 Water Street, New Salem PA, 15468 Site Location: 0194
Address (Main Street Bridgeville)
1371 Main St, Brdigeville Pa 15017-2664 Site Location: 0059
Address (McClane)
17 McClane Ave, Washington PA 15301-3332 Site Location: 0136
Address (MKinley)
555 McKinley Ave, Washington PA 15301-3938 Site Location: 0003
Address (Michigan Ave)
730 Michigan Ave APT M18, Washington PA 15301-1778 Site Location: 0015
Address (Morrow)
434 Morrow Ave, Carnegie PA 15106-2069 Site Location: 0076
Address (Nebraska)
108 Nebraska Dr, New Kensington PA 15068-3241 Site Location: 0084
Address (North Main Street, Houston)
692 N Main St, Houston PA 15342-1615 Site Location: 0139
Address (Oak Hill)
71 Oak Hill Drive Washington, PA 15301
Address (Oklahoma Salem)
3146 Oklahoma Salem Rd, Dubois Pa, 15801-5845 Site Location: 0100
Address (Pacific)
1414 Pacific Ave, Monaca PA 15061-1827 Site Location: 0165
Address (Paige)
2652 Paige St, New Kensignton PA, 15068-3132 Site Location: 0058
Address (Pine)
23 Pine St, Washington PA, 15301-3579 Site Location: 0054
Address (Pinkerton 105 #1)
105 Pinkerton Dr, Beaver PA , 15009-1213 Site Location: 0151
Address (Pinkerton 114 #2)
114 Pinkerton Dr, Beaver PA , 15009-1214 Site Location: 0156
Address (Reno)
299 Reno St, Rochester PA, 15074-2008 Site Location: 0154
Address (Reynoldsville)
1167 Route 322, Reynoldsville PA, 15851-4257 Site Location: 0097
Address (Ridgemont)
465 Ridgemont Dr, Pittsburgh PA, 15220-5233 Site Location: 0183
Address (Rockton)
5343 Rockton Rd, Dubois PA, 15801-2959 Site Location: 0186
Address (Saxonburg)
2134 Saxonburg Blvd, Cheswick PA 15024-1709 Site Location: 0069
Address (Sherwood)
182 Sherwood Dr, Verona PA, 15147-3318 Site Location: 0191
Address (Smithtown)
832 Smithtown Road Reynoldsville, PA 15851 Site Location: 0197
Address (Smyerstown Rossiter)
311 Smyerstown Rd, Rossiter PA 15772-9210 Site Location: 0105
Address (Springdale)
536 Pittsburgh St, Springdale PA, 15144-1410 Site Location: 0187
Address (Springfield)
197 Springfield Ave, Washington PA, 15301-5262 Site Location: 0091
Address (Spruce Street)
319 Spruce St, Beaver PA 15009-1126 Site Location: 0184
Address (State Park Road/Penfield)
1015 State Park Rd, Penfield PA, 15849-1133 Site Location: 0102
Address (Sunset)
100 McClelland Rd, Claysville PA, 15323-1380 Site Location: 0022
Address (Tyler)
240 Tyler Ave, Washington PA, 15301-1778 Site Location: 0034
Address (Washington Street)
801 Washington Street Natrona Heights, PA 15065 Site Location: 0199
Address (West Walnut)
38 W Walnut St, Washington PA, 15301-4320 Site Location: 0182
Address (Wildlife)
930 Wildlife Lodge Rd, New Kensington PA, 15068-2758 Site Location: 0180
Address (Morgan)
103 Morgan Lane Monaca PA 15061 
Site Location:
Name of Facility
Address
City
Zip-Code
Service Location ID
MPI
Date and Time of Incident*

MonthDayYear
DateHourMinutesAM/PM Option
Place Incident Occurred (ex. House, Community Location, Jobsite)*
Describe in detail exactly what happened*
Staff Witnessing Incident
Describe Involvement
Staff Witnessing Incident
Describe Involvement
Did the incident involve Seizures, Dehydration, Constipation, Choking, or Falling?*

YesNo
Please select all that apply.*

SeizuresDehydrationConstipationChokingFall
SEIZURES

Mild Symptoms Intense Symptoms
Staring Loss of consciousness
Unresponsive Brief muscle jerks and spasms
Confused Loss of bladder or bowel
Twitching of face Limp/collapse on floor
Lip smacking Rigid muscle tone and jerking
Numbness/tingling in body Change in breathing pattern

What to Do During a Seizure

Ensure safe surroundings Provide padding under person’s head Loosen clothing, jewelry around neck Stay with person
Remove glasses Check for breathing throughout seizure
Turn person on side

Do Not!
 Do not put anything in mouth (cannot swallow tongue!)
 Do not restrain or hold the person down (cannot stop a seizure!)
 Do not give anything to eat or drink until fully awake (person may choke/ aspirate!)
 Do not attempt artificial respiration unless not breathing

Call 911 if:

 It is the person’s first seizure
 The person is not breathing
 The seizure lasts over 5 minutes
 Seizures continue one after another without the person regaining consciousness
 Head or other bodily injury occurred during seizure
 Seizure occurs in the water
Follow your agency policies.
Seizure-Duration*
Seizure-Actions Taken*
DEHYDRATION

Causes of Dehydration

Diarrhea and vomiting
Sweating excessively
Fever
Medication side effects

Medical conditions – diabetes undiagnosed or
uncontrolled, kidney disease, Crohn’s disease
Inability to communication thirst
Reliance on caregivers to provide fluids
Aging changes that lead to dehydration

Signs of Dehydration

Dry mouth Weak
Headache Thirsty
Dizzy/lightheaded Decrease in urination
Sleepy/difficult to arouse Dark concentrated urine
Dehydration-Temperature*
Dehydration-Actions Taken*
Constipation

Causes of Constipation

Lack of fiber Associated with medical conditions diabetes
Inadequate fluids Stroke, cerebral palsy, Down syndrome
Lack of exercise Not enough time to use the toilet
Side effects of medications

Symptoms of Constipation

Small, hard stools Refusing to participate in activities
Crying, grimacing, grunting, straining on toilet Lack of appetite Rectal digging Avoids using the bathroom due to pain
Hitting abdomen Staying in the bathroom for long periods
Hard, protruding abdomen Fever
Constipation-Days Since Last Bowel Movement*
Constipation-Actions Taken*
CHOKING/ASPIRATION

Causes of Choking

Poor Eating Habits Medical Reasons for Choking
Eating too fast Dry mouth
Placing large amounts of food in mouth Decayed /missing teeth
Choosing not to wear dentures Difficulty chewing/swallowing
Poor posture Aging
Eating food different from consistency of one’s food Certain medications
GERD

Signs of Choking

Severe coughing, gagging Anxious/agitated
Hitting chest Red face
Putting hands on throat Noisy breathing
Unable to talk Skin color change – gray or blue
Unable to breath Loss of consciousness

ONE SINGLE CHOKING EVENT MAY BE A WARNING SIGN FOR FUTURE CHOKING EVENTS.
Choking-What was choked on?*
Choking - Actions Taken (back blows, heimlich, or chest compressions)*
Falls - Environmental Conditions*
Falls - Terrain*
Falls - Actions Taken*
Did the incident involve any form of a restraint?*

YesNo
Please select level of PEI utilized.*

PEI Level 1PEI Level 2PEI Level 3Other
PEI Level 1*

Bear Hug Control - One staff memberSafety/Two Arm Assist Techniques - One staff memberSafety/Two Arm Escort Techniques - One staff memberTwo Person Secured Escort - Two staff membersTwo Person Two Arm Control Escort - Two staff membersTwo Person Two Arm Standing Restraint - Two staff membersStanding Restraint - One staff member
PEI Level 2*

One Person Assist to the FloorOne Person Assist to the Floor with staff #2 securing the legsSeated Floor Restraint
PEI Level 3*

Supine Restraint
Please describe in detail restraint used*
Did the restraint last longer than 30 minutes within a 2 hour time frame?*

YesNo
Cumulative amount of time restraint was used in a 2 hour time frame. (Indicate minutes and/or seconds)*
Was First Aid Administered or body check completed?*

YesNo
If yes, describe in detail: *
Did this incident involve a medication error?*

YesNo
Name of Medication*
Date and time of discovery

MonthDayYear
DateHourMinutesAM/PM Option
Error due to*

Staff ErrorRefusal by individualOther
What type of medication error was it? (select all that apply)*

Omission - missed a dose of medicationWrong Dose - Gave too much or too little medication during a scheduled administrationWrong Form - Gave the wrong form of the medication (e.g. gave a tablet instead of a liquid)Wrong Medication - Gave an extra dose of medication that should not have been givenWrong Medication - Gave discontinued medicationWrong Medication - Gave medication that was supposed to be given for another reasonWrong Person - Gave Person someone else's medicationWrong Position - Person was positioned improperly to receive medicationWrong Route - Gave medication by the wrong routeWrong Technique/Method - MEdication was prepared improperly (e.g. not shaking a suspension prior to administeringWrong Time - Gave medication too early or too late
Staff position of the person giving medication*

Direct Care StaffSupervisory StaffRNLPNManagement or Administrative StaffIndividualOther
Did the error occur over multiple consecutive administrations?*

YesNo
Did the error occur due to a failure to implement medication changes in a timely manner?*

YesNo
Due to answers selected, this incident is now considered neglect and a report needs filed as such.
Why did the error occur? (select all that apply)*

Another individual obtained unattended medicationDid not compare log to labelDid not get prescription or refill from health care providerDid not order prescription or refill from pharmacyDid not pick up prescription or refill from pharmacyDid not receive prescription ordered from pharmacyError in Medication Administration Record (MAR)/Medication LogGot wrong prescription from pharmacyMiscommunication between residential provider and day service providerMisidentified personMismeasured liquid medicationMisread labelMixed up size or strength of tabletsUnknownOther
What was the response to the error? (select all that apply)*

Called poison controlContacted health care professionalContacted program supervisorDiscovered too late to do anythingER visitHad blood level of medication doneHospitalizationObserved for side effectsOther
Name of person completing this form*

First NameLast Name
Signature/Title of person completing this form *

Clear
This next section is to be completed by a Program Specialist or Director. Are you that person?*

YesNo
What was or will be the agency system response to prevent this type of error from occurring in the future? (Med Error)

Evaluate new policy/modified existing policyEvaluate new practice/modified existing practiceHCQU referralIndicator for quality improvement initiativeIndividual feedback to employeeMonitoring medication passes for that staff personReferral to risk management for further evaluationSituation reviewed, no action takenTraining/RetrainingOther
Name of staff involved

First NameLast Name
Was the staff involved working longer than their regular work hours at the time of the error? (Med Error)

YesNo
Length of time staff involved has been giving medication. (Years) (Med error)
Number of medications supposed to be given to this individual at the same time as the error was made including the medication where the error was made?
Number of medications this individual receives on a daily basis? (Does not include medications that are taken on an episodic basis)
Number of people (including this individual) that the staff involved has to give medications to around the same time as the error occurred?
Were any medications involved in this medication error a controlled substance?

YesNo
Please specify the medications.
Was parent, guardian, residential provider, SC or BCM notified?*

YesNo
Who was notified?*

ParentGuardianResidential providerSupports CoordinatorBlended Case ManagerOther
Name(s) of people notified*
You can list multiple people in this field as identified above (separate with commas).
Date notified*

MonthDayYear
Date
How were they notified?*

By PhoneIn WritingOther
Were supports offered to the individual/victim?*

YesNo
What supports were offered to the individual/victim? (Medical Attention)*

Assessment of InjuryCPR AdministeredEmergency RoomFirst AidHospitalPrimary Care PractitionerUrgent Care CenterNot ApplicableOther
If no, explain: *
Other Supports*

Contacted Local Domestic Violence ProviderContacted Local Rape Crisis CenterFormal CounselingLocal Behavioral Health Crisis InterventionRespiteVictim/Witness ServicesNot ApplicableOther
Was a call made to 911?*

YesNo
If yes, explain: *
Program Manager/Supervisor or Program Director to contact if any of the following apply:

*Additional Notification Required if Abuse, Neglect, Exploitation, or Abandonment:

Under 18

1) In addition to ensuring the health and safety and following agency protocol, a report MUSTBE made to Childline at #1-800-932-0313 or https://www.compass.state.pa.us/cwis/public/home

Age 18-59

1) An oral report should be made by calling the statewide Protective Services Hotline #1-800490-8505

2) If suspected abuse or neglect involves sexual abuse, serious injury, serious bodily injury, or a suspicious death then one must also contact PA DHS/APS Division at (717) 265-7887 AND local law enforcement

3) Within 48 hours of making the oral report to the hotline, a written report must be faxed to #484-434-1590 or emailed to Liberty Healthcare at mandatoryron@libertyhealth.com. (The report should be a printout of the EIM print summary)

*Refer to the matrix for additional reporting requirements if law enforcement is involved or serious bodily injury has occurred*

Protective Services Hotline - 1-800-490-8505
OAPSA (Over 60) Oral Report to Local Area Agency on Aging (AAA) Office*

YesNoN/A
APS (18-59)*

YesNoN/A
Has an EIM report been completed for this incident?*

YesNo
What date was the EIM report entered?*

MonthDayYear
Date
Please list the incident number(s)*
The above information is complete and accurate to the best of my knowledge.

YesNo
Time

:HourMinutesAM/PM Option
Should be Empty:

ARC HUMAN SERVICES INCIDENT REPORT