* Incident Report

Incident Report

SPECIAL INCIDENT REPORT

State Requirement, ALL Instructors/Education Consultants must create an incident report here within 4 days if the client is missing. If a client has not been seen for 5 days or on the 5th consecutive day of an UNPLANNED absence the Instructors/Education Consultants must report here immediately. If a Instructors/Education Consultants has not reported the client missing then the Instructors/Education Consultants will be reported to Adult Protective Services for negligence and client abandonment. The Instructors/Education Consultants may also be faced with disciplinary actions or termination. If a law suit results from the Instructors/Education Consultants negligence then the Instructors/Education Consultants will cover all legal charges and fee's or fines applicable.

HOW TO RESPOND TO AN INCIDENT:
Things To Remember When A Special Incident Occurs

Insure: the safety of the consumer
Notify : ACRC, CCL, APS/Ombudsman, Police, Family, DHS, or coroner as required
Check: for completeness of information on incident report
Inquire: into inconsistencies
Document: details
Explore: causes of the incident
Note: necessary additions or corrections to SIR
Track: SIR follow-up and completion

* Indicates required field

STAFF INFORMATION

Today's Day of the week *

Your Name *

First

Last

Job Title *

What time did the incident occur? *

1st Finish time *

2nd time start (IE: After lunch) *

2nd Finish time (IE:After Lunch) *

Did you take a break? *

Instructor Weekly Schedule
(please fill it out Weekly Schedule
it is required if your schedule is not filled out then it will be noted that you are not working this week and therefore did not return in a leave request.

CLIENT INFORMATION

Client Name (Please Type) *

First

Last

Client Learner Name *

Ratio *

Is this a late entry? *

Reason for late Entry *

Is this a report? Make sure your clients reports are current. *

Location of service *

City *

State *

Client Phone Number *

Does this client have an upcoming appointment of any kind this week? *

What kind of appointment? Contact person & e-mail or number? *

SERVICE INFORMATION

Case Manager Name *

First

Last

Service Provided (ILS or Parenting)? *

Task Performance *

BIRP Progress Notes (must be filled out completely otherwise this date of service will not be paid) *

Upload documents (Receipts or Court Documents etc) *

Max file size: 20MB

Upload Current Photo of Your Client & Children (monthly) *

Max file size: 20MB

Suspected Abuse/Exploitation *

Serious Injury/Accident *

Victim of Crime *

Injury/Accident *

Agression Displayed by consumer(limited to incidents where injury was incurred (notable bruising, scratching, etc.) *

Suspected Neglect *

Any unplanned or Unscheduled Hospitalization: *

Other Serious Incident *

Relationship of alleged perpetrator or consumer (used for neglect or abuse, and victim of crime only) *

Incident location *

Other agencies notified *

Name of person contacted *

First

Last

Phone Number *

Description of incident Include Significant Events Before Incident Occured *

Immediate Action Taken *

Specific preventative action taken or planned by the vendor *

Witness to the Incident Name and Contact Telephone Numbers (If more than one add the other person to the notes) *

First

Last

Phone Number *

I certify that by typing and providing my first and last name or initials in the bellow consultant E-Signature slot under penalty of perjury that the above information and any information pertaining to clients or hours work that have been turned into LeBlanc Consulting by me for myself, or for anyone affiliated with LeBlanc Consulting is accurate. I agree that any misrepresentation here with my hours or by billing for more hours will lead to immediate termination. Otherwise I may face prosecution and be required to pay back monies that are inaccurately billed for as well as any legal cost to pursue this matter. I agree and understand that If I am not claiming mileage now that I am not entitled to come back at a later date and claim millage. I know if I am falsely claiming mileage or hours worked that this is fraud and can be pursued in the court of law. I agree that I am in the right mind and body when I am submitting my documentation and when I saw the client. I understand that any false misrepresentation of the clients, LeBlanc Consulting or the Regional Center of the East Bay can lead to prosecution and is subject to a law suit and paying legal fees. I certify that the consumer(s) listed above was/were provided the service as authorized for the stated periods, and that no additional charges were made to other parties. These claims are submitted under penalty of perjury in accordance with the terms and conditions below.

The Provider agrees and shall certify under penalty of perjury that all claims for service provided to Regional Centers have been provided to the consumer(s) by the Provider.
The services were, to the best of the Provider's knowledge, provided in accordance with the consumer's written Individual Program Plan.
The Provider shall also certify that all information submitted to the Regional Center is accurate and complete.
The Provider understands that payment of these claims will be from the federal and/or state funds and any falsification or concealment of a material fact may be prosecuted under federal and/or state laws.
The Provider agrees to keep for a minimum period of five years from the date of service, a printed and/or electronic representation of all records which are necessary to disclose fully the extent of services furnished to the client.
The Provider agrees to furnish these records and any information regarding payments claimed for providing the services, on request, within the State of California, to the California Department of Healthcare Services; Medi-Cal Fraud unit; California Department of Developmental Services; California Department of Justice; Office of the State Controller; U.S. Department of Health and Human Services, or their duly authorized representatives.
The Provider also agrees that services are offered and provided without discrimination based on race, religion, color, national or ethnic origin, sex, sexual orientation, age, or physical or mental disability.
The Provider agrees that they are in compliance with Welfare and Institutions Code Section 4514, Health Insurance Portability and Accountability Act (HIPAA), and all other applicable state and federal statutes and regulations regarding confidentiality of consumer information.

Did you double check your work? If you did not double check your work and you submit a note with mis information such as putting 1pm-2pm and you actually worked 5 hours the 5 hours the lesser will paid. It is up to you to double check your work, It takes time for the IT department to pull your note back up. This menu will NOT allow you to return once the note has been completed. Incompetent notes will not be accepted, honored or paid. Please submit with care and caution.

Consultant Digital Signature (Client is unavailable to sign consent but has verbally consented to the indicated services) By Signing, Instructor Agrees to the following statements above. *

First

Last

Type your first and last name so that we can identify who you are. Your signature should contain your full first and last name. Please do not put your initials. Please be sure that your note is complete. Once you turn in the note you will not be able to go back and make changes. By accessing this information, I agree that I am the rightful person qualified to use this system by LeBlanc Consulting and that no one other than me is currently using this system. I agree that I have permission to access this system by LeBlanc Consulting and that I agree to use this system responsibly. This page contains confidential information and by using this web page and entire website I have agreed to company secrecy and the legal use of this private information for the sole purposes of Le Blanc Consulting only. I agree to not copy this information in any way or form such as rewording or changing the documents to meet the needs of any other company. I agree to not compete with LeBlanc Consulting under any circumstances for the length that this company is in operation or vendored with the Regional Centers. Therefore, by submitting this document this serves as my official no compete clause and I agree to company secrecy. I know and agree that this is my official no compete clause which I sign every time I log into the computer. I agree to use this system responsibly. I agree to professional secrecy and this is my formal non disclosure acknowledgement. If I am found to use this information or any of the information thereof it can be punishable by termination or possible suit in the court of law. I agree that if I misuse this information which may lead to a case in the court of law will be my sole responsibility to pay for all attorney and court fees for myself and LeBlanc Consulting. I agree that if I have questions about this system that I will contact LeBlanc Consulting Information technology department to get those questions answered and I will not consult with an entity outside of LeBlanc Consulting. The direct contact time log/progress notes are to be typed immediately upon entering a client's home to assist in the retention of important and sometimes critical information, only submit the contact log as you are leaving the client's home otherwise your hours will look short in the computer system. Be sure to start filling out the note as you are communicating with the client as the computer times the amount of time you have spent at the client's home and can pinpoint your location as well. As you are going through the lesson plan use the tools on our database. I agree that I will log into the system when i enter the client's home since I know that the system allows us to see how long you are logged into the client IP address at their home. I agree that if I log onto this computer system from anywhere other than the client's home that this may be grounds for termination and I may be terminated without notice. I am aware that If I do not bill at the time of services, my hours may not be paid. I am aware that that maximum hours I can work with clients is based on their service agreement and I shall not go over the amount of hours permitted daily unless approved by a supervisor. I agree that If I go beyond those hours provided within the service agreement without permission for a supervisor that I may not get paid. I am also aware that parenting hours are 20 per month and ILS hours are 40 hour per month per client depending on how the service agreement is written, however I will check with my supervisor to see if any of my client hours have been used so that I do not go over their allowed hours per month. I agree that if I go over the client hour that it may not be paid. PLEASE READ BEFORE FILLING OUT THIS NOTE: If you are hired with LeBlanc Consulting you are considered a contract employee until your 90 day probation period is up. After your 90 day probation period then you are considered permanent. At this point LeBlanc Consulting will issue an ID Badge. The ID Badge is to be used simultaneously with this computer login system. Log into the computer as you arrive to the client's home,no later than 1-5 hours after services are provided. If the note is NOT filled out in it's entirely then you will not be paid for services you are stating that you rendered. If you submit a note with the same information from the last time you saw the client(cutting and pasting information) then the note will not be paid, if you submit all of your notes late or at the last minute (on the 30th and or its more than 5 days late) you will not be paid. If you state you saw the client and did not actually see the client and you are paid, then you will have to reimburse LeBlanc Consulting for the monies paid to you. If LeBlanc Consulting discovers that you have not seen your client which causes the company to lose the purchase orders for that client then LeBlanc Consulting has the right to request the fees for the remainder of contracted POS. Any mistakes were made where you were paid more than what you worked, or if you falsely claimed hours that you did not work, or if you quit your job with LeBlanc Consulting the Company reserves the right to obtain its funds for up to 5 years from the date of services. If you refuse to repay the moneys for the fraudulent claims then a letter will be sent to collections. After 3 collection attempts (3 months) A Lawsuit will be filed on the behalf of LeBlanc Consulting to obtain the money paid to you. If there is a special incident please file a special incident report immediately & our office and we will send it over to RCEB, or CPS.

Submit progress note