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Indiana State Department of Health

ISDH Home > Long Term Care > Incident Reporting by Long Term Care Facilities Incident Reporting by Long Term Care Facilities

Incident Reporting by a Nursing Home

This page is intended to provide comprehensive care and residential care facilities with information on the reporting of incidents to the Indiana State Department of Health (ISDH).  Except where otherwise stated, this page applies to:

  • Comprehensive care facilities (nursing homes)
  • Residential care facilities (licensed assisted living)  

This page is not intended for consumers for the submitting of complaints about a health care facility.  Consumers should go to the Reporting a complaint web page at www.in.gov/isdh/21533.htm for information on reporting a complaint. 

This page is also not intended for "covered individuals" for the Reporting a reasonable suspicion of a crime against a resident.  Providers should go to the Reporting a reasonable suspicion of a crime against a resident web page at www.in.gov/isdh/25766.htm for information. 

Contact the ISDH

Indiana State Department of Health
Division of Long Term Care
2 North Meridian Street, 4B
Indianapolis, IN 46204
(317) 233-7442 (Long Term Care Receptionist)
(317) 233-1325 (ISDH Main Switchboard)
Map

Complaint and Incident Reporting Program Director
Karen Smith
Email:  ksmith@isdh.in.gov
Phone: 317-233-7709
Fax: 317-233-7494

Director, Division of Long Term Care
Kim Rhoades
Email:  krhoades@isdh.in.gov
Phone:  (317) 233-7289
Phone:  (317) 233-9691 [Administrative Assistant]
Fax:  (317) 233-7322

Acronyms and Definitions

Acronyms

  • CMS:  Centers for Medicare and Medicaid Services
  • ISDH:  Indiana State Department of Health 

How to Report an Incident to the ISDH

Incident Reporting System

The preferred method to report an incident is through the ISDH Incident Reporting System.  The Incident Reporting System is an online system located on the ISDH Gateway at the same location as the Survey Report System.  Health care facilities can access the Gateway at https://gateway.isdh.in.gov/. If a follow-up report is needed, the facility submits the follow-up report through the Incident Reporting System.

Report Submission

  1. Online Incident Reporting System through the ISDH Gateway
    1. All incident report information must be submitted through the Online Incident Reporting System effective July 1, 2015.
    2. Information submitted by fax or voice mail will not be accepted after July 1, 2015.
    3. The link to the Online Incident Reporting System is: https://gateway.isdh.in.gov/.   (Quick Guide – Instructions for the Online Incident Reporting System & Frequently Asked Questions are available for assistance.)
  2. Submission of the Report of Reasonable Suspicion of a Crime Against a Resident Form.
    1. If an incident being reported also constitutes a suspicion of a crime, the Report of Reasonable Suspicion of a Crime Against a Resident form located at http://www.in.gov.isdh/25766.htm can be submitted simultaneously through the document upload feature in the Online Incident Reporting System.  
    2. If the reasonable suspicion of a crime against a resident is not associated with an incident, the form can be submitted through email at incidents@isdh.in.gov.   The form should indicate it is not a reportable incident.
  3. Information related to an evacuation or an event involving the Emergency Management Agency must be reported to 317-460-7287 at any time.

Reporting when online system is Nonoperational

  1. If the Online Incident Reporting System is nonoperational, the Incident Reporting Form located at http://www.in.gov/isdh/23638.htm must be completed and emailed to incidents@isdh.in.gov
  2. Within 24 hours of the emailing the Incident Reporting Form, the complete information about the incident MUST BE entered into the Online Incident Reporting System and include the date and time of the Incident Reporting Form was emailed.
  3. If both the Online Incident Reporting System and the email system is not available, the information can be reported to 317-460-7287 and leaving a voicemail message that includes the following information:  
    1. Name & Title of Reporter
    2. Name of Facility
    3. Address of Facility
    4. Type of Incident (examples on Incident Reporting Form)
    5. Injury
    6. Name of Resident(s)
    7. Name of Staff Involved
    8. Immediate Action Taken

Note:  The voicemail option is only to be used when both the online and email systems are nonoperational.  

Report Information

  1. The Initial Report information should include the following:
    1. Facility information
    2. Name and job title of staff completing the report
    3. Actual or Identified Date and Time of the Incident
    4. Name(s) of resident(s) involved
    5. Name and title of staff involved
    6. Brief description of event
    7. Type of injury(s) sustained
    8. Immediate action taken to respond to the event and protect the resident
    9. Preventive measures taken while the investigation is in process
  2. The Follow Up Report information should include the following:
    1. Results of the investigation
    2. Interventions implemented or corrective action taken 
    3. Method in which facility will continue to monitor efficacy of plan/interventions
    4. Other persons or agencies to which the incident was reported. 
  3. Initial and Follow Up Report can be submitted together if all of the necessary information has been obtained within the timeframe for initial reporting.    

Forms

Incident Report Form

If the Online Incident Reporting System is nonoperational, the Incident Reporting Form must be completed and emailed to incidents@isdh.in.gov.  Within 24 hours of the emailing the Incident Reporting Form, the complete information about the incident MUST BE entered into the Online Incident Reporting System and include the date and time of the Incident Reporting Form was emailed.  The Incident Report Form is to be used by health care facilities for the reporting of reportable incidents.  This form may be used by acute care and long term care facilities, centers, agencies, or clinics to notify the ISDH of a reportable incident.  The Incident Report Form is not to be used by covered individuals to report a reasonable suspicion of a crime against a long term care facility resident or by consumers to file a complaint.

Laws and Regulations

Comprehensive Care Facility (Nursing Home) Regulations

CMS Regulation:  42 CFR 483.13(c)(2) states:

The facility must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State Survey and Certification Agency).  [For procedures, see ISDH LTC Reportable Incidents Policy]

State Rule:  410 IAC 16.2-3.1-13(g)(1)

(g)   The responsibilities of the administrator shall include, but are not limited to, the following:

(1) Immediately informing the division by telephone, followed by written notice within twenty-four (24) hours, of unusual occurrences that directly threaten the welfare, safety, or health of the resident or residents, including, but not limited to, any:

(A) epidemic outbreaks;
(B) poisonings;
(C) fires; or
(D) major accidents.

Residential Care Facilities (licensed assisted living)

State Rule:  410 IAC 16.2-5-1.3 Administration and management

(g)  The administrator is responsible for the overall management of the facility. The responsibilities of the administrator shall include, but are not limited to, the following:

(1)  Informing the division within twenty-four (24) hours of becoming aware of an unusual occurrence that directly threatens the welfare, safety, or health of a resident. Notice of unusual occurrence may be made by telephone, followed by a written report, or by a written report only that is faxed or sent by electronic mail to the division within the twenty-four (24) hour time period. Unusual occurrences include, but are not limited to:

(A) epidemic outbreaks;
(B) poisonings;
(C) fires; or
(D) major accidents.

Program Guidance and Advisory Letters

ISDH Program Policies and Procedures

Page Last Updated:  July 28, 2015