Fillable QUALITY IMPROVEMENT CBAS INCIDENT REPORT (CalOptima)

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QUALITY IMPROVEMENT CBAS INCIDENT REPORT (CalOptima)

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QUALITY IMPROVEMENT – CBAS INCIDENT REPORT
PLEASE FORWARD TO:
CalOptima Quality Improvement Department
505 City Parkway West, Orange, CA 92868
Email: qualityofcare@caloptima.org / FAX: 657-900-1615
Date of Notification: CBAS Name:
CBAS Address:
Name of Staff Member
Reporting the Incident:
Member Name:
Member DOB
(MM/DD/YYYY):
CIN #:
Gender
(M/F)
Health Network
Diagnosis
PHYSICIAN/PROVIDER
Name:
License #:
ADDRESS
(where incident occurred)
Name:
Address:
DOI (Date of Incident)
(MM/DD YYYY)
REASON FOR REFERRAL
(Check Appropriate Box)
Communication problem
Inappropriate behavior
Service issue
System/Operations issue
Fall, accident, etc. requiring admission to acute facility
OTHER (please explain):
CRITICAL INCIDENT
[any actual or alleged event or situation that creates a significant risk of substantial or
serious harm to the physical or mental health, safety or well-being of a member]
(Check Appropriate Box)
abusive or demeaning language by caretaker
Use of bodily or chemical restraints on an individual which is
not in compliance with federal or state laws and administrative
regulations
act which cause injury or death to an individual or which
OTHER (please describe)
Unauthorized use or the use of excessive force in the
placement of bodily restraints on an individual
SUMMARIZE THE INCIDENT
Attach related records and supporting documentation including reports made to other CalOptima departments
INCIDENT SUMMARY:
OTHER DEPARTMENTS CASE REFERRED TO:
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QUALITY IMPROVEMENT CBAS INCIDENT REPORT (CalOptima)

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Completed 11 March 2021

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