Incident Investigation Follow-Up Review Form Instructions

Standard for Supervisor ResponsibilityIncident Investigation/Follow-upYesNoCommentsSection may be used to clarify a response given, butmay not be used as a stand-alone response.3. The summary of findings, including areview of the individual’s relevantprogram plan and interventionstrategies (if applicable) incomparison to the activitiesdescribed in #2 are recorded.This standard is NO if, as applicable:a. Elements described in a-g above are not recorded, orb. A clear reason for not recording elements a-g is notdocumented.This standard is YES if:a. Summary findings of the investigation are recorded,including a summary of a review of the individual’srelevant program plan and interventions strategies (ifapplicable) that should have been used compared to theactivities described in #2 above.4. Conclusions from the informationprovided in 1-3 above are recorded.This standard is NO if:a. Summary findings of the investigation are not recorded,orb. Summary findings do not include a review of theindividual’s relevant program plan and interventionstrategies that should have been used compared to theactivities described in #2 above; orc. A clear reason for not recording elements a-b are notdocumented.This standard is YES if:a. The outcome of the incident is recorded.5. Recommendations from theinformation provided in 1-4 above arerecorded.This standard is NO if:a. The outcome of the incident is not recorded, orb. A clear reason for not recording the outcome of theincident is not documented.This standard is YES if:a. Recommendations based on information gathered duringthe investigation to improve the quality of care for theindividual are recorded.This standard is NO if:a. Recommendations based on information gathered duringthe investigation to improve the quality of care for theindividual are not documented, orb. A clear reason for not recording recommendations is notdocumented.Standard for Team Leader ResponsibilityIncident Investigation/Follow-up1. A description of how the incidentaffected the individual is recorded(if applicable).YesNoCommentsSection may be used to clarify a response given, butmay not be used as a stand-alone response.This standard is YES if:a. The incident’s effect on the Individual s recorded; orb. An explanation is present that the incident did not haveDMHDDAS Incident Report and Incident Investigation/Follow-up Audit Tool Instructions-Effective 11/1/08-Page 3 of 4