To: Sandhills Center Catchment Area Providers
*Category A & B Providers Only*
From: Pam Morgan, Quality Management Director
Date: July 1, 2010
Re: Level I Incident Quarterly Report Reminder
The DHHS Incident and Death Response system requires all Providers of publicly
funded services licensed under G.S. 122-C (except hospitals), (Category A
Providers) and Providers of publicly funded non-licensed periodic or community
based mh/dd/sa services (Category B Providers) to adhere to Incident and Death
Reporting requirements. This includes outpatient, residential, licensed day and day
treatment providers. Failure to do so may result in DHHS taking administrative
action against the provider’s license or authorization to provide services.
Providers are required to report aggregate information on Level I incidents
involving restrictive interventions, medication errors, and searches and seizures to
the Host LME on a quarterly basis. The information must be submitted on the
DHHS Level I Incident Quarterly Review Report Form, QM 11. See attached.
Information on 4th quarter incidents (April-June) will be due no later than
July 10, 2010. Reports should be completed for each site/service location within
the Sandhills catchment area (Anson/ Harnett / Hoke / Lee / Montgomery / Moore /
Randolph / Richmond counties).
A Level I quarterly report must be submitted to the LME even if there have been no
incidents of medication errors, restrictive interventions or search and seizures.
Providers should indicate 0 incidents for this situation. If a provider has not
provided services during this quarter a report must be submitted. This applies to all
Please send your reports to Angie Kivett at 108 W Walker Avenue, Asheboro, NC
27203, by email at firstname.lastname@example.org or by fax 336-625-3661. Angie
may also be reached at 336-625-4351
Thank you for your cooperation!