AFC Licensing Division Incident/Accident Report

METHODS FOR SUBMITTING AN INCIDENT REPORT UPON THE 
DEPARTMENT’S REQUEST:

1. Submit Incident/Accident Report using the online form.
2. Submit Incident/Accident Report using the fillable form by mail, fax or email to the licensing staff member requesting the report.

LICENSING RULES FOR AFC FAMILY HOMES & SMALL/LARGE GROUP
HOMES

FAMILY HOME: R 400.1416a Incident notification, incident records.

SMALL/LARGE GROUP HOMES: R 400.14311 Incident notification, incident 
records. Rule 311. (1) 

(1) If a resident has a representative identified in writing on the resident’s care 
agreement, a licensee shall report to the resident's representative within 48 
hours after any of the following: 
    (a) Unexpected or unnatural death of a resident.

    (b) Unexpected and preventable inpatient hospital admission. 

    (c) Physical hostility or self-inflicted harm or harm to others resulting in 
    injury that requires outside medical attention or law enforcement 
    involvement. 

    (d) Natural disaster or fire that results in evacuation of residents or 
    discontinuation of services greater than 24 hours. 

    (e) Elopement from the home if the resident’s whereabouts is unknown. 

(2) If an elopement occurs, staff shall conduct an immediate search to locate 
the resident. If the resident is not located within 30 minutes after the 
elopement occurred, staff shall contact law enforcement.

(3) An incident must be recorded on a department-approved form and kept 
in the home for a period of not less than 2 years. 

(4) The department may review incident reports during a renewal inspection 
or special investigation. This does not prohibit the department from 
requesting an incident report if determined necessary by the department. If 
the department does request an incident report, the licensee shall provide 
the report in electronic form within 24 hours after the request. The 
department shall maintain and protect these documents in accordance with 
state and federal laws, including privacy laws.

LICENSING RULES FOR AFC CONGREGATE FACILITIES
R 400.2404a Incident notification, incident records. Rule 404a. 

(1) As used in these rules: 

    (a) "Department" means the department of licensing and regulatory 
    affairs. 

    (b) "Elopement" means a resident that has a service plan that requires 
    notice or arranged supervision to leave the facility and is absent without 
    notice or supervision. 

    (c) "Incident" means, consistent with the incident recordkeeping 
    requirement in this rule, an intentional or unintentional event where a 
    resident sustains physical or emotional harm, an unexpected or 
    unnatural death, is displaced by a natural disaster, or elopes. 

(2) If a resident has a representative identified in writing on the resident’s care 
agreement, the licensee shall report to the resident's representative within 48 
hours after any of the following: 

    (a) Unexpected or unnatural death of a resident. 

    (b) Unexpected and preventable inpatient hospital admission. 

    (c) Physical hostility or self-inflicted harm or harm to others resulting in 
    injury that requires outside medical attention or law enforcement 
    involvement. 

    (d) Natural disaster or fire that results in evacuation of residents or 
    discontinuation of services greater than 24 hours. 

    (e) Elopement from the home if the resident’s whereabouts is unknown. 

    (f) If an elopement occurs, staff shall conduct an immediate search to 
    locate the resident. If the resident is not located within 30 minutes after 
    the elopement occurred, staff shall contact law enforcement. 

(4) An incident must be recorded on a department-approved form and 
    maintained in the home for a period of not less than 2 years. 

(5) The department may review incident reports during a renewal inspection 
    or special investigation. This does not prohibit the department from 
    requesting an incident report if determined necessary by the department. If 
    the department does request an incident report, the licensee shall provide 
    the report in electronic form within 24 hours after the request. The 
    department shall maintain and protect these documents in accordance with 
    state and federal laws, including privacy laws.