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CONSUMER INCIDENT, ACCIDENT, ILLNESS, DEATH OR ARREST REPORT
MACOMB COUNTY COM MU NITY MENT AL HEALTH SERVICES
FACILITY/HOME FACILITY CODE__________ RESIDENT/RECIPIENT
FACILITY ADDRESS AGE SEX M( ) F( )
CITY STATE ZIP CASE NUMBER
LICENSEE/ORGANIZATION NAME LICENSEE NUMBER
P E R S O N S IN V O L V E D /W IT N E S S E D
NAME NAME
HOME ADDRESS/STREET & NUMBER HOME ADDRESS/STREET & NUMBER
PHONE NUMBER PHONE NUMBER
DATE OF INCIDENT, ACCIDENT, ILLNESS, DEATH OR ARREST TIME LOCATION
EXPLAIN WHAT HAPPENED INDICATOR CODE _________
ACTION TAKEN BY STAFF
ACTION TAKEN TO REMEDY AND/OR PREVENT REOCCURRENCE OF INCIDENT, ACCIDENT, ILLNESS OR DEATH
NAME OF TREATING PHYSICIAN/HEALTH CARE/MEDICAL FACILITY/HOSPITAL PHONE NUMBER DATE AND TIME CARE GIVEN
( ) AM
( ) PM
PHYSICIAN’S DIAGNOSIS OF INJURY/ILLNESS, CAUSE OF DEATH IF KNOWN
PERSON(S) NOTIFIED NOTIFICATION PERSON(S) NOTIFIED NOTIFICATION
DATE/TIME DATE/TIME
ADULT FOSTER CARE LICENSING ( )A ADULT PROTECTIVE SERVICES (IF APPLICABLE) ( )AM
( )PM ( )PM
PHYSICIAN OR RN (IF APPLICABLE) ( )AM OFFICE OF RECIPIENT RIGHTS (IF APPLICABLE) ( )AM
( )PM ( )PM
RESPONSIBLE MCCMHS CASE MANAGER ( )AM LAW ENFORCEMENT AGENCY (IF APPLICABLE) ( )AM
( )PM ( )PM
RESPONSIBLE MCCMHS SUPERVISOR ( )AM OTHER (PLEASE SPECIFY) ( )AM
( )PM ( )PM
SIGNATURE OF PERSON COMPLETING REPORT PRINT NAME & TITLE DATE
SIGNATURE OF LICENSEE/ADMINISTRATOR PRINT NAME & TITLE DATE
COMPLETED IR’S GENERATED AT CONTRACT AGENCIES: RETAIN 1 COPY IN ADM. FILE; FORWARD 1 COPY TO RESPONSIBLE MCCMHS AGENCY AND 1 COPY TO AFC LICENSING IF REQUIRED.
DIRECT OPERATED MCCMHS AGENCIES: RETAIN 1 COPY IN ADM. FILE; FORWARD 1 COPY TO BOARD OFFICE OF RECIPIENT RIGHTS. RESPONSIBLE CMH AGENCY FORWARDS CONTRACT
AGENCY IR’S TO ORR.
Consumer Incident, Accident, Illness, Death or Arrest Report, MCCMH #190, MCCMH MCO Policy 9-321, Exhibit A
100 VENTURES 174 GILBERT* 245 CHOICES OF LIFE SKILLS *A11 E M E RG E N T P S YC H IA T RIC H O SP IT A L A D M IS S IO N
101 FIRST RESOURCES NORTH 175 GREATER MACK* 246 NEW PORT ROAD *A12 E M E RG E N CY N ON -P S YC H . H O SP A DM IS S IO N
102 FIRST R ESO URC ES & T X S.W . 176 GREENFIELD* 247 LEDGE STONE A13 U N PL A NN E D P S YC H . E R R O O M EV A LU A TIO N
103 FIRST RESOURCES & TX S.E. 177 GREENSBOROUGH* 248 LIBERTIES A14 PHYSICAL INJURY REQUIRING ER TREATMENT
104 VOCATIONAL & DAY PROGRAM 178 GRUBER* 249 T.T.I. (PROVIDER) *A15 DESTRUCTION OF PROPERTY BY A RECIPIENT
106 CROSSROADS CLUBHOUSE 179 HARBORVIEW 250 S T . C LA IR H O M E A16 S U SP E CT E D C R IM IN A L A C T C O M M IT T E D B Y /O R
107 W A S H IN G T O N M A N OR 180 HIGHLITE* 251 JEWELL POINTE - (27 MILE ROAD) AGAINST A RECIPIENT
109 MADISON HOUSE 181 HOW ARD’S COVE 252 ABRAHAM *A17 SERIOUS VERBAL HOSTILITY
110 CAROL MAN OR (f.k.a. Bousson) 182 INDIAN HILLS* 253 C H ES T ER F IE L D H O M E *A18 SERIOUS DISPLAY OF BEHAVIORAL HOSTILITY
111 O T T ER H O M E 183 JEWELL ROAD* 254 MACOMB CHILDREN’S RESPITE A19 INAPPROPRIATE SEXUAL ACTS AND/OR
112 MACOMB RESPITE 184 JUDGES COURT* 255 C.S.D.D. - WARREN CONTACT BY A RECIPIENT OR BETWEEN
113 MCARC INC 185 JUNCTION* C.S.D.D. - NEW HAVEN RECIPIENTS
114 BIRCH CREST 186 KANTON* 256 E.H.S. (CRISIS STABILIZATION) *A20 FIRE
115 LIFE SKILLS CENTER ROSEVILLE 187 KELLY* 257 BAKER *A21 ARREST AND/OR CONVICTION OF A RECIPIENT
(13 Mile Road) 188 LAKEVIEW * 258 MAC OM B LIFE SKILLS (CLINTO N TW P.) *A22 UNAUTHORIZED L.O.A.
116 ARAB CHALDEAN PROGRAM 189 LAMBRECHT* 259 NEW PASSAGES PSYCH. SVC. *A23 SEIZURE LIKE ACTIVITY
117 METS 190 LITTLE MACK* 260 OAKLAND PSYCH. SERVICES A24 VEHICLE ACCIDENT
118 NATURAL FREEDOM (PROVIDER) 191 LOW E PLANK* 263 CATHOLIC SOCIAL SERVICES A25 CONTACT W / BLOOD/BODY FLUIDS OF ANOTHER
119 CHILDREN’S HOME OF DETROIT-W ARREN 192 MACKEY* — W ARREN A26 OTHER
CHILDR EN’S HO ME O F DET ROIT -G.P.W . 193 D.E.S. - W AYNE EAST - (S.C.S.) 264 CATHOLIC SOCIAL SERVICES
120 MANOR FOUNDATION (MARC) 194 SHELBY LIFE SKILLS* — C LINTO N TW P. * The critical ORR/QA Indicators with asterisks must be reported
121 NORTH MACOM B SKILL BLDG. CENTER 195 MACOMB MAINTENANCE* 265 EASTW OOD CLINIC to the designate d licensing agent.
122 SOUTH MACOMB SKILL BLDG. CENTER 196 MEADOW DALE* — EASTPOINTE
123 SPECIAL RESIDENTIAL SERV. 197 MIDDLE RIVER* 266 EASTW OOD CLINIC GROUP B - M E DI CA T IO N - RELATED ERRORS
124 M A C O M B T R AN S IT IO N A L L IV IN G H OM E 198 MILE END* — CLINTON TWP.
125 CLEAVE HOUSE 199 MILE STONES 267 RADCLIFT HOUSE B1 SUSPECTED ADVERSE REACTION TO MEDS.
126 C H EY E NN E HO M E 200 MOUND* 268 NICHOLSON* B2 STAFF ADMINISTRATION OF INCORRECT MEDS.
127 KINGSBERRY* 201 MULVEY* 269 R O S EW O O D H O M E B3 S T AF F A D M IN IS T RA T IO IN O F IN C O RR E CT D O SA G E
128 SITTER SERV. - CHILD 202 CALLENS GROUP HOME* 270 E D G EM O N T HO M E B4 STAFF ADMINISTRATION OF MEDICATION AT
129 SITTER SERV. - ADULT 203 N O T T IN G H AM * 271 SHELBY PROGRAM IN C O RR E CT T IM E
134 HATHAW AY HOUSE 204 O’CONNOR* 272 HAB WAIVER CONSUMERS B5 STAFF ADMINISTRATION OF MEDS. AFTER
135 MAPLE LANE 205 OMO 273 I. O .M . ORDER DISCONTINUED/EXPIRED
136 S T O NE S T. FA IR W E A T HE R LO D G E 206 BELLE MEADE AFC/WELLNESS 274 NEW PASSAGES PORTABLE SUPPORTS B6 PHYSICIAN INCORRECTLY PRESCRIBED
137 S U G AR B US H GR O U P H O M E 207 PARKWAY* 275 ZACHARY B7 RECIPIENT FAILURE TO TAKE PRESCRIBED MEDS
138 SILVER KNOLL 208 PINE VALLEY* 276 PEMBERTON HOUSE B8 R E CIP IE N T R E FU S ED S CH E DU L ED M E DIC A TIO N
139 S IL V ER M E AD O W S 209 POUND* 277 CREATIVE SALES (CEO MT. CLEMENS) B9 P H AR M A CY E RR O R
140 OBRA TREATMENT 210 RAY CENTER* 278 ACCESS CENTER B10 MEDICATION DISPOSAL
141 BRANDENBERG 211 ROAN* 279 FAIRFIELD B11 OTHER
142 SIP DD 212 RONDALE* 280 A U TU M N M AN O R B12 S T AF F F A IL E D T O A DM IN IS T ER M E DIC A TIO N
143 S IP M I 213 RUEDISALE* 282 LEELANE
144 ALBERT* 214 SASS* 283 TROMBLEY
145 ALT. PERSONNEL, INC. 215 SENECA* 284 BRODERICK GROUP C - STAFF INCIDENTS
146 SOARING HEIGHTS 216 SHELLY COURT* 285 IN HOME SVCS-ADULT
147 PAM MCDONALD HOME* 217 SPRINGBROOK* 286 IN HOME SVCS-CHILD
C1 VEHICLE ACCIDENT
148 ASHBURTON* 218 STERLING NORTH* 287 PIERCE AFC*
C2 STAFF INJURY
149 ROMEO LIFE SKILLS (RLS) 219 STONEY CREEK* 288 OCCUPATIONAL/EDUCATIONAL CNTR.
C3 HAZARDOUS CONDITIONS
150 BELLOWO ODS* 220 SULA* 289 JEWISH VOCATIONAL SERVICE
C4 CONTACT WITH BODY FLUIDS
151 BORDMAN* 221 ULRICH* 290 STERRIT HEIGHTS
152 BRIDGEVIEW * 222 VAN DYKE* 291 MACOMB FAMILY SVCS - CLINTON TWP
153 BRUCE HILLS* 223 W INSTON HOME* MACOMB FAMILY SVCS - SHELBY TWP
154 CAPAC* 224 W EST UTICA*
155 CASS* 225 DODGE PARK*
156 CHAPMAN* 226 ROMEO HOME *MORC FACILITIES UPDATED JULY 6, 2005
157 CLEARVIEW * 227 KOLARIK* (Form/Fa cility&IRc odelist)
158 CLINTON RIVER* 228 JUDSON CENTER FOR CLARIFICATION ON DEFINITIONS BELOW, SEE
159 COPPERFIELD* 229 W EYER* THE NEW IR DEFINITIONS POSTER - EFFECTIVE
160 C. E. O. I - DESIGN LANE 230 SHERWO OD* 4/1/05
C. E. O. II - SOUTH ROSE 231 S T ER L IN G H OM E
161 CRYDERMAN* 232 L IL LIA N HO M E GROUP A - HIGH RISK/DANGEROUS SITUATIONS
162 DARW IN* 233 MOROW SKE INVOLVING RECIPIENTS
163 DEV. ESSENTIAL SERV. I* - CLINTON TWP 234 D E ER W O O D
164 DEV. ESSENTIAL SERV. II* - ROMEO 235 HIDDEN OAKS *A1 DEATH OF RECIPIENT Consumer Incident, Accident, Illness,
165 THE LEARNING CENTER 236 FRIENDSHIP HOUSE *A2 SERIOUS SELF INFLICTED HARM Death or Arrest Report
166 EATON* 237 CEDAR GROVE *A3 NON SERIOUS SELF INFLICTED HARM
167 EVANSTON* 238 S H O RE S MA N O R
MCCMH #190
A4 SUICIDAL ATTEMPT
168 FISHER* 239 C O U NT Y M AN O R A5 SUICIDAL THREAT MCCMH MCO Policy 9-361, Exhibit A
169 FISHER ESTATES* 240 MEADOW LANE A6 HOMICIDAL ATTEMPT (Page 2)
170 FORBES* 241 RIVIERA A7 HOMICIDAL THREAT
171 FOX HILL* 242 W INDMILL POINT A8 SUSPECTED SEXUAL ABUSE/NEGLECT
172 FULTON* 243 JAMES A9 SUSPECTED PHYSICAL ABUSE/NEGLECT
173 GARBOR* 244 BAYRIDGE A10 SUSPECTED VERBAL ABUSE/NEGLECT
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