Critical Incident Report

Freedom Healthcare, LLC and Lighthouse Behavioral Health Center, LLC

Policy

A written critical incident report is required for significant events involving persons served, staff, volunteers, visitors, operations, or safety.

Procedure

Complete all applicable sections with factual details, immediate actions taken, and supporting documents, then submit for supervisory and quality review.

NOTE: Required fields must be completed before submission.

Incident Information

Incident Date *

Specific Location

Identification of Staff, Volunteer, Person Served, and/or Visitor (Family/Support, Stakeholder) Involved in Incident

Person Served C1

Date of Birth

Chart Number

Admission Date

Person Served C2

Date of Birth

Chart Number

Admission Date

Staff/Volunteer S1

Position

Program

Staff/Volunteer S2

Position

Program

Visitor V1

Home

Cell

Type of Critical Incident and Individual Involved

(As noted by code - C1, C2, S1, S2, V1)

Type of Critical Incident and Individual Involved *

Incident Description

Facts: What, When, Who, How (Additional sheets may be added)

Immediate Action Taken & Rationale

Identify Other Agencies Involved in Treatment

Pertinent Information About Person Served

(Diagnosis, Medications, Summary of Type & Frequency of Services)

Report Prepared By

Report Prepared by

Date

Title

Department

Other Agencies Notified

(e.g., OHCQ, APS, CPS, Sheriff, Police, etc.)

Additional Actions Taken Since Incident

Follow-Up Plan

Written Report Routing

Reporter will forward report to the Supervisor, who will complete the comment section, sign it, and forward the original copy to the Quality Management Director within 24 hours of the incident.
The Quality Management Director will forward a copy within 24 hours to the Human Resource Director if the critical incident involves staff/volunteer injury.
A copy of the Critical Incident Report form will be forwarded by the Supervisor within 1 hour of completion to the Program Director for any occurrence of seclusion or restraint.
If the incident is of a critical nature that may impact operations, reputation, service delivery, or create liability, the Quality Management Director will forward it to the CEO within the same business day.
Verbal reporting to executive leadership must occur immediately following any death, suicide, serious injury, abuse allegation, or any event with potential public or legal exposure.