This document outlines an organization's incident reporting policy and procedures. It defines incidents as events that are not part of routine operations or care that could adversely affect individuals receiving supports. Incidents are classified into three levels based on their impact. All incidents must be reported within 24 hours, with Level II and III incidents reported to the local management entity within 72 hours. The procedures describe requirements for responding to incidents, notifying authorities, compiling reports, investigating causes, and implementing preventative measures. The goal is to protect health and safety while complying with regulations.

1. Incident Reporting
Kaleo Supports, Inc
Training Manual

2. Learning Objectives
• What is the definition of an “incident”?
• What are the different levels of an “Incident”
• What behaviors would determine the level of an incident?
• What are provider categories?
• What are the reporting requirements for incidents?
• What is an “Incident Report”?
• Where do you report an incident?

3. Incident Reporting
• Policy on Incident Reporting:
• Kaleo Supports, Inc. will comply with ethical standards and state regulations in providing accurate and
timely information in incident and accident reports. It is the position of Kaleo Supports to make every
effort to protect the health, safety and well-being of the people receiving services/supports from the
company.
• Procedures:
• Definition: “Incident” means any happening which is not consistent with the routing operation of a facility
or service or the routine care of a person receiving supports and that is likely to lead to adverse effects
upon a person receiving supports.
• 10 NCAC 27G.0103b)32 of the North Carolina Administrative Code.
• 10NCAC 27G.0602(507) includes the following:
 Level I incident- does not meet the definition of Level II or Level III
 Level II incident- results in a threat to the health and or safety of a person receiving supports; or a threat to the health
and or safety of others due to actions by a person receiving supports and does not meet the definition of a Level III
 Level III incident- results in: (a) a death, permanent physical or psychological impairment to a person receiving
supports; (b) a death, permanent physical or psychological impairment caused by a person receiving supports; or (c) a
threat to public safety caused by a person receiving supports.
 “Provider category” means the type of place in which a person receives supports or resides. The provider category
determines the extent of monitoring that a provider receives and is determined as follows:

4. Incident Reporting
• Provider Categories are as follows:
 Category A-facilities licensed pursuant to G.S. (General Statue) 122C, Article
2, except for hospitals; these include 24-hour residential facilities, day
treatment and outpatient services. (10 NCSN 27G.0602(10)(a)
 Category B– G.S. 122C, Article 2, community based providers not requiring
State licensure. (10 NCAC 27G.0602(10)(b)
1. Level I, II or III incidents will be responded to by:
 Attending to the health and safety of the individuals involved in the incident;
 Determining the cause of the incident;
 Developing and implementing corrective measures;
 Developing and implementing measures to prevent similar incidents;
 Assigning person(s) to be responsible for implementation of the corrections and
preventive measures;
 Maintaining documentation regarding the above

5. Incident Reporting
2. In addition to the above, Kaleo Supports shall respond to a Level III incident that occurs
while a person is receiving supports from Kaleo Supports or is on the premises of Kaleo
Supports by:
a. Immediately securing the individual’s record
Obtaining the individual’s record
Making a photocopy
Certifying the copy’s completeness;
Transferring the copy to the review team
b. Convening a meeting of the review team within 24 hours of the incident.
The review team shall:
• Consist of a minimum of the Director of Clinical Support, direct support staff who provide of the service, the case
manager and other’s deemed necessary and/or appropriate.
• Review the individual’s record
• Gather needed information
• Issue a report concerning the incident to Kaleo Supports, the individual’s home area authority/LME to facilitate the
monitoring of services as required by G.S. 122C-111 and other State Statues

6. Incident Reporting
• C. The Qualified Professional who completes the report shall immediately notify the following:
• The LME responsible where the supports are provided
• The individual’s guardian as applicable
• Others required by law
3. All incidents must be reported to the Director of Supports within 24 hours. Level II and Level III incidents will be
reported to the LME within 72 hours of the incident. The incident will be reported on the form as provided by the
State and may be submitted by mail, in person facsimile or other electronic means. The report shall include the
following:
 a. Kaleo Supports contact and identification information
 The individual’s identification information
 Type of incident
 Description of incident
 Status of the effort to determine the cause of the incident
 Other individuals or authorities notified or responding
4. Any missing or incomplete information shall be explained. Within one business day, Kaleo Supports shall update the report by:
a. Notify the LME when it has reason to believe that information provided in the report may be erroneous, misleading otherwise
unreliable and
b. Submitting to the LME information required on the incident report form that was missing or not available.
5. Kaleo Supports will provide, upon request of the LME other information obtained regarding the incident such as:
a. Hospital records including confidential information
b. Reports by other authorities
c. Kaleo Supports response to the incident, including any corrective action

7. Incident Reporting
• 6. Quarterly reports are due to the LME ( on a form provided by the State) summarizing Level I
incidents
• and the reports shall include the following:
– a. Medication errors that do not meet the definition of a Level II or Level III incident
– b. Searches of an individual’s living area
– c. Seizures of an individual’s property or property in the possession of an individual.
d. Reporting of restraints will also occur
7. Kaleo Supports shall send a copy of all Level III incidents reports to the Division of Facility Services and Division
of Mental Health, Developmental Disabilities and Substance Abuse Services for Category A providers and to
Division of Mental Health Developmental Disabilities and Substance Abuse Services for category B providers
immediately upon receipt of the report.
8. Employees shall report to the Director of Supports immediately all incidents, unusual occurrences and/or situations
that need attention.
9. Employees who witness or who are involved in an incident or accident must ( within 24 hours) contact the Director
of Supports or designee. The employee is responsible for completing his or her portion of the incident form. The
following steps shall take place regarding the form:
1. The employee shall complete the form and submit to the Director of Supports or designee within 24 hours
2. The Director of Supports or designee shall review, sign and file the form as well as initiate any action deemed necessary upon
evaluation of the incident
3. The Director of Supports or designee shall make all necessary reports, including verbal reports to the LME as deemed appropriate.

8. Incident Reporting
10. The Director of Supports will review each incident and implement corrective actions in order to
prevent future occurrence of similar incidents
11. Examples of incident and accident reports for documentation include, but are not limited to:
a. any injury, including self-injurious behavior, which requires medical treatment by a physician.
(First aid is not included in this category)
b. medication errors, including lack of administering a prescribed medication, which causes
discomfort or places his/her health and safety in jeopardy
c. use of hazardous substance that requires medical treatment by a physician. (First aid is not
included in this category)
d. elopements (escape, run away) lasting more than 3 hours
e. an individual’s death
f. suspension or expulsion of an individual from services/supports
g. any case of abuse, neglect or exploitation against an individual which is under investigation or
has been substantiated by a county Department of Social Services (DSS) or the DFS Health Care
Personnel Registry Section;
h. any suicide attempt
i. The arrest of an individual for violations of state, municipal county, or federal law
j. Any fire or equipment failure that places the health and safety of an individual in jeopardy

9. Incident Reporting
12. All employees must report allegations of abuse, neglect and/or exploitation ( whether witnessed or
suspected) to the county Department of Social Services
13. Incident Report Forms, the investigation to evaluate incidents, the review of incidents shall be filed in a
separate administrative file rather than the individual’s record
14. Only the following will be documented in an individual’s record regarding any incidents:
a. Description of the event
b. Actions taken on behalf of the individual
c. The individual’s condition following the event
15. The Quality Assurance Team will review trends of incidents

10. Kaleo Supports, Inc.
I acknowledge that I have participated in the training session:
Incident Reporting
I have had the opportunity to ask any questions.
I understand it is my responsibility to know this information.
If I need more training or material, I am to see the Director of Supports.
Employee signature__________________________________Date_______
Facilitator
Signature:__________________________________________Date_______