CRS Incident Reporting Process

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The Purpose of Incident Reporting

The Department of Health Services is required by the Centers for Medicare and Medicaid Services (CMS) to ensure the health, safety and welfare of home and community-based services participants. The Department assigns and shares this responsibility, in part, to and with local Medicaid agencies, service providers, and guardians and family members. The state uses incident reports to identify statewide or regional patterns and trends, which allow the development of interventions to decrease the likelihood of re-occurrence of such incidents. It is imperative that an incident reporting process be developed, maintained, and faithfully followed.

The Incident Reporting Process

Incident reporting is always a person-specific process. If an incident involves or affects multiple CRS participants, a separate report must be submitted for each participant affected by the incident. Incident reporting is part of a larger incident response process. The process begins when the Medicaid agency, service provider or guardian or family member observe or learn of an event or discover a situation that conforms to the definition of an incident. Providers and guardians or family members must inform Medicaid agencies of such incidents and Medicaid agencies must both notify and report the event and the response to the assigned state contact as specified in the instructions.

The incident reporting form and instructions are provided below. Please familiarize yourself with both, and implement them in your organization for your CRS consumer population. Incident reporting is required for your CRS consumers.

  • Incident Report Form - F-00390 (Word Fillable)
  • Incident Reporting Instructions - F-00390i


Last Revised: July 6, 2015