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CA HHSA LIC 624 1999-2025 free printable template
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION UNUSUAL INCIDENT/INJURY REPORT INSTRUCTIONS NOTIFY LICENSING AGENCY PLACEMENT AGENCY AND RESPONSIBLE PERSONS IF ANY BY NEXT WORKING DAY. SUBMIT WRITTEN REPORT WITHIN 7 DAYS OF OCCURRENCE. RETAIN COPY OF REPORT IN CLIENT S FILE. NAME OF FACILITY FACILITY FILE NUMBER ADDRESS CITY STATE ZIP TELEPHONE NUMBER CLIENTS/RESIDENTS INVOLVED TYPE OF INCIDENT s Unauthorized...Absence s Aggressive Act/Self s Alleged Violation of Rights DATE OCCURRED Alleged Client Abuse s Sexual s Physical s Psychological s Financial s Neglect s AGE Rape Pregnancy Suicide Attempt Other SEX DATE OF ADMISSION Injury-Accident Injury-Unknown Origin Injury-From another Client Injury-From behavior episode Epidemic Outbreak Hospitalization Medical Emergency Other Sexual Incident Theft Fire Property Damage Other explain DESCRIBE EVENT OR INCIDENT INCLUDE DATE TIME LOCATION PERPETRATOR NATURE...OF INCIDENT ANY ANTECEDENTS LEADING UP TO INCIDENT AND HOW CLIENTS WERE AFFECTED INCLUDING ANY INJURIES PERSON S WHO OBSERVED THE INCIDENT/INJURY EXPLAIN WHAT IMMEDIATE ACTION WAS TAKEN INCLUDE PERSONS CONTACTED LIC 624 4/99 OVER MEDICAL TREATMENT NECESSARY YES NO IF YES GIVE NATURE OF TREATMENT WHERE ADMINISTERED ADMINISTERED BY FOLLOW-UP TREATMENT IF ANY ACTION TAKEN OR PLANNED BY WHOM AND ANTICIPATED RESULTS LICENSEE/SUPERVISOR COMMENTS NAME OF ATTENDING PHYSICIAN NAME AND TITLE DATE REPORT...SUBMITTED BY REPORT REVIEWED/APPROVED BY AGENCIES/INDIVIDUALS NOTIFIED SPECIFY NAME AND TELEPHONE NUMBER LICENSING ADULT/CHILD PROTECTIVE SERVICES LONG TERM CARE OMBUDSMAN PARENT/GUARDIAN/CONSERVATOR LAW ENFORCEMENT PLACEMENT AGENCY.
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How to fill out a CA HHSA 624 Form
What is the CA HHSA 624 Form?
The CA HHSA LIC 624 Form is a crucial document required by California's health and human services sector. Its purpose is to report unusual incidents or injuries that occur within care facilities. Timely and accurate reporting not only helps maintain compliance with state regulations but also ensures the well-being of clients.
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This form serves to officially document incidents, which is critical for regulatory review and accountability.
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All licensed facilities and service providers dealing with vulnerable populations must complete this form.
How do you complete the CA HHSA 624 Form?
Completing the CA HHSA LIC 624 Form involves several sections that require detailed information regarding the incident.
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Provide essential details about the facility, including its name, address, and licensing information.
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Document specifics about the incident, such as date, time, and nature of the event.
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Outline any medical care provided to the individual affected by the incident.
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List all parties notified of the incident, ensuring compliance with reporting laws.
What are the essential fields in the CA HHSA 624 Form?
Every section of the CA HHSA LIC 624 Form offers specific fields that must be filled out thoroughly to avoid delays or rejection.
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This section must be precise, including official business names and full address.
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Capture the client’s age, sex, and date of admission for comprehensive documentation.
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Include a detailed description of the incident, along with any significant deviations from standard procedures.
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Indicate any planned actions or treatments following the incident, ensuring proper care continuity.
What are the compliance guidelines for reporting?
Compliance with the required reporting guidelines is non-negotiable for facilities submitting the CA HHSA LIC 624 Form.
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Agencies and individuals must be notified in compliance with California law.
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Reports need to be reviewed within a specified timeframe to ensure prompt action.
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Failing to submit the CA HHSA LIC 624 Form or improper reporting can lead to penalties and loss of license.
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Using pdfFiller for the CA HHSA LIC 624 Form simplifies the entire process of completion and submission.
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What common errors should you avoid?
Preventing errors is crucial to ensure that the CA HHSA LIC 624 Form is processed without any issues.
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Missing fields can lead to delays or rejection of your form; double-check each section.
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Familiarize yourself with California regulations to avoid unexpected compliance issues.
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Always review your submission for accuracy and completeness before finalizing.
What happens after you submit the CA HHSA 624 Form?
Understanding the post-submission process is essential for managing incidents effectively.
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After submission, you can track the form's status and anticipate response times.
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Agencies will review the submitted reports to ensure compliance and follow-up as necessary.
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Prepare for potential follow-up inquiries or additional documentation requests from agencies.
Frequently Asked Questions about lic624 form
What is the CA HHSA LIC 624 Form used for?
The CA HHSA LIC 624 Form is utilized to report unusual incidents and injuries in care facilities. It is essential for ensuring compliance with state regulations and for maintaining client safety.
Who is responsible for submitting the CA HHSA LIC 624 Form?
Licensed facilities and service providers where incidents occur are responsible for submitting the CA HHSA LIC 624 Form. All relevant staff need to be aware of the process to ensure timely reporting.
How can pdfFiller help with the CA HHSA LIC 624 Form?
pdfFiller provides tools that simplify the process of filling out, editing, and signing the CA HHSA LIC 624 Form. Users can collaborate in real-time and manage documents efficiently from the cloud.
What common mistakes should I avoid when filling out the form?
Common mistakes include leaving fields incomplete and not adhering to compliance requirements. Always verify each section to ensure that all necessary details are provided.
What should I do after submitting the CA HHSA LIC 624 Form?
After submission, it’s important to track the form's status and be prepared for any follow-up requests from the reviewing agency. Keep a copy of the submission for your records.
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People Also Ask about unusual incident report
What are unusual incident injury report form used for?
Form LIC 624, Unusual Incident/Injury Report, is an document created for daycare providers that allows them to report unusual incidents and/or injuries to the appropriate California state agencies.
What is an example of an unusual incident?
UNUSUAL EVENT OR INCIDENT: Unusual incidents include resident abuse, unexplained absences, or anything that affects the physical or emotional health or safety of any resident and epidemic outbreaks, poisonings, catastrophes, facility fires or explosions.
What is an unusual occurrence incident report?
The unusual occurrence report is a guide to walk through a thorough investigation for a root cause analysis. An unusual occurrence report is to be completed for all injuries/accidents or any situation/occurrence that could pose a safety risk to patients or staff.
What is LIC 624?
LIC 624 - Unusual Incident/Injury Report.
Which of the following is an unusual incident?
Unusual Incident means incidents involving serious illness or accidents, death of an individual, injury or illness of an individual requiring inpatient or emergency hospitalization, suicide attempts, a fire requiring the services of a fire department, an act of physical aggression, or any incident requiring abuse
What is an example of unusual occurrence?
Unusual Occurrence means events or situations that do not happen daily or that may have had an impact on children. such as: fire drill interrupted sleep, visitor came with puppets, fear of a dog on a walk. It may by something that happened to the whole group of children or just to an individual child.
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