HOME CARE SERVICES INITIAL NOTICE OF INCIDENT
INCIDENTS MUST BE REPORTED IMMEDIATELY AFTER TAKING ACTIONS TO ADDRESS PERSON'S HEALTH AND SAFETY NEEDS.
Instruction: Please DO NOT use initials & abbreviations in narrative and for agency names. File a separate incident for each participant involved (except mass emergency), then please call the division immediately!
Participant Information
Client First Name
*
Client Middle Name
Client Last Name
*
Waiver
ALF
LTC
CCW
*
Date of Incident
*
*
*
Location (City)
*OUT OF STATE
*STATEWIDE
ACME
AFTON
ALADDIN
ALBANY
ALBIN
ALCOVA
ALPINE
ALTA
ALVA
ARAPAHOE
ARLINGTON
ARMINTO
ARVADA
ATLANTIC CITY
AUBURN
BAGGS
BAIROIL
BANNER
BAR NUNN
BASIN
BEAR RIVER
BECKTON
BEDFORD
BEULAH
BIG HORN
BIG PINEY
BIG SANDY
BIG TRAILS
BILL
BITTER CREEK
BONDURANT
BORDER
BOSIER
BOSLER
BOULDER
BOXELDER
BRIDGER
BUCKHORN
BUFFALO
BUFORD
BURGESS JCT
BURGESS JCT.
BURLINGTON
BURNS
BURNTFORK
BURRIS
BYRON
CALPET
CANYON
CARLILE
CARPENTER
CARTER
CASPER
CENTENNIAL
CHEYENNE
CHUGWATER
CLARETON
CLARK
CLEARMONT
CODY
COKEVILLE
COLONY
CORA
COWLEY
CRESTON JCT
CROWHEART
DANIEL
DAYTON
DEAVER
DEVILS TOWER JCT
DEVILS TOWER JCT.
DIAMONDVILLE
DIXON
DOUGLAS
DUBOIS
E. THERMOPOLIS
EDEN
EDGERTON
EGBERT
ELK BASIN
ELK MOUNTAIN
ELKOL
ELMO
EMBLEM
ENCAMPMENT
ERVAY
ESTERBROOK
ETHETE
ETNA
EVANSTON
EVANSVILLE
FAIRVIEW
FARSON
FEDERAL
Fontanelle
FORT BRIDGER
FORT LARAMIE
FORT WASHAKIE
FOUR CORNERS
FOX PARK
FRANNIE
FREEDOM
FRONTIER
GARLAND
GILLETTE
GLENDO
GLENROCK
GRANGER
GRANITE CANYON
GRASS CREEK
GREEN RIVER
GREYBULL
GROVER
GUERNSEY
HAMILTON DOME
HAMPSHIRE
HANNA
HARMONY
HARRIMAN
HARTVILLE
HAWK SPRINGS
HILAND
HILLSDALE
HOBACK JCT
HOBACK JCT.
HOBACK JUNCTION
HORSE CREEK
HUDSON
HULETT
HUNTLEY
HYATTVILLE
IRON MOUNTAIN
JACKSON
JAMESTOWN
JAY EM
JEFFREY CITY
JELM
JENNY LAKE
KAYCEE
KEELINE
KELLY
KEMMERER
KINNEAR
KIRBY
LA BARGE
LA GRANGE
LAGRANGE
LAKE
LAMONT
LANCE CREEK
LANDER
LARAMIE
LEITER
LIGHTNING FLAT
LINCH
LINGLE
LITTLE AMERICA
LONETREE
LOST CABIN
LOST SPRINGS
LOVELL
LUCERNE
LUSK
LYMAN
LYSITE
MADISON JCT
MAMMOTH SPRINGS JCT
MANDERSON
MANVILLE
MARBLETON
MAYOWORTH
MCFADDEN
MCKINNON
MEDICINE BOW
MEETEETSE
MERIDAN
MERNA
MIDWEST
MILLBURNE
MILLS
MONETA
MOORCROFT
MOOSE
MORAN
MORAN JCT
MORRISEY
MORTON
MOSKEE
MOUNTAIN HOME
MOUNTAIN VIEW
MULE CR JCT
NATRONA
NEW HAVEN
NEWCASTLE
NODE
NORRIS JCT
OLD FAITHFUL
OPAL
ORIN
ORPHA
OSAGE
OSHOTO
OSMOND
OTTO
PARKMAN
PAVILLION
PIEDMONT
PINE BLUFFS
PINE HAVEN
PINE TREE JCT
PINEDALE
PITCHFORK
POINT OF ROCKS
POWDER RIVER
POWELL
PRAIRIE CENTER
QUEALY
RALSTON
RANCHESTER
RAWLINS
RECLUSE
RED DESERT
REDBIRD
RELIANCE
RENO JCT
RIVERSIDE
RIVERTON
ROBERTSON
ROCK RIVER
ROCK SPRINGS
ROCKYPOINT
ROLLING HILLS
ROZET
SAGE
SARATOGA
SAVAGETON
SAVERY
SHAWNEE
SHELL
SHERIDAN
SHOSHONI
SINCLAIR
SLATER
SMOOT
SOUTH AFTON
SOUTH PASS CITY
SPOTTED HORSE
ST. STEPHENS
STAR VALLEY RANCH
STORY
SUNDANCE
SUNRISE
SUPERIOR
SUSSEX
TABLE ROCK
TEN SLEEP
TETON
TETON VILLAGE
THAYNE
THERMOPOLIS
TIE SIDING
TORRINGTON
TOWER JCT
TURNERVILLE
UCROSS
UPTON
URIE
VALLEY
VAN TASSELL
VETERAN
W. THUMB JCT
WALCOTT
WALTMAN
WAMSUTTER
WAPITI
WASHAM
WENDOVER
WESTON
WHEATLAND
WILSON
WOODS LANDING
WORLAND
WRIGHT
YODER
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Date of Report
Person Reporting
*
Phone
Email
Title or Relation To The Client
*
Provider Information
Service
S5101U7-Adult Day Services (Health Model)
S5101-Adult Day Services (Social Model)
T2031-Assisted Living Facility
T2031U8-Assisted Living Facili
T2022-Case Management (Monitoring)
T2024-Case Management (Service Plan Development/Annual Update)
T2022UB-Case Management- Monitoring with Training Certificate
S5165NU Environmental Modification
S5165 Environmental Modifications-Repair
T2040-Fiscal Management Services
S5170-Home Delivered Meals (Frozen)
S5170SE-Home Delivered Meals (Hot)
T1004-Home Health Aide
S5130 Homemaker
T2004-Non-Medical Transportation (Non-Wheelchair Accessible Vehicle)
T2003-Non-Medical Transportation (Public Transit Multipass)
A0120-Non-Medical Transportation (Service Route)
A0130-Non-Medical Transportation (Wheelchair Accessible Vehicle)
S5160CG-PERS (Cellular Installation)
S5161U4-PERS (Cellular Monitoring)
S5161-PERS (Landline Monitoring)
S5199 Personal Care Items, NOS
S5160-Personal Emergency Response System (PERS) (Landline Installation)
S5125-Personal Support Service
S5125U5-Personal Support Servi
S5151-Respite (Out-of-Home, Assisted Living Facility)
S5150-Respite Care Services (In Home)
H0045-Respite (Out-of-Home, Nursing Facility)
T1003-Skilled Nursing Services
T1002-Skilled Nursing Services
A4928 Surgical Mask per 20
T2025-Transition Intensive Case Management
T2025UB-Transition Intensive Case Management w/ Training Certificate
T2038-Transition Setup Expenses
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If other, please specify:
Organization
307 CORNERSTONE CASE MANAGEMENT, LLC
5150 Case Management
A.C.E. CASE MANAGEMENT, LLC
ACES$ FISCAL MANAGEMENT SERVICES
ADT Medical Alert Systems (PERS), LLC
Advantage Healthcare
AFFINITY CASE MANAGEMENT LLC
Alert Medical Alarms Inc
ALIGN SERVICES, LLC
ALL ABOUT FAMILY, INC.
ALL ABOUT INDEPENDENCE LLC
ALLIANCE CASE MANAGEMENT
Alpine Case Management
AS WE GROW - LADEANA BROWN
ASPEN WIND ASSISTED LIVING COMMUNITY
AUNKIA FOWLER AND ASSOCIATES, LLC.
B.A.C.A. CASE MANAGEMENT, LLC
BEAR COUNTRY HOME HEALTHCARE, LLC
Belladaire Holdings
BEST HOME HEALTH & HOSPICE, LLC
BIGHORN SECURITY, LLC
BRAIN INJURY ALLIANCE OF WYOMING
BUFFALO SENIOR CENTER
Cambria Heights LLC
Campbell & Crew, LLC
CAMPBELL CO. HOME HEALTH AND HOSPICE
CARBON COUNTY SENIOR SERVICES
Carmen Harrison Case Management
CHEYENNE REGIONAL MEDICAL CENTER HH
CITY OF CHEYENNE TRANSIT (CTP)
COCOON CASE MANAGEMENT
CODY COUNCIL ON AGING
COMMUNITY HOME HEALTH SERVICE, LLC
Compassionate Home Care LTD
COMPASSIONATE HOME CARE LTD (OLD)
COMPASSIONATE JOURNEY, LLC
COMPASSIONATE JOURNEY, LLC - ALF
CONNECT AMERICA, LLC
Conrad's Case Management
CONTINUE CARE OF CHEYENNE
CORPORATE PROTECTIVE SERVICES
COWBOY CARES INC
CROOK COUNTY SENIOR SERVICES
Deb's Case Management Services LLC
Devoted Case Management, LLC
EMERGENCY LIFELINE WEST
EMPOWER REHABILITATION AND CASE MANAGEMENT, LLC
Enhabit Health Home Health
EPPSON CENTER FOR SENIORS, INC
EPSILON HEALTH SOLUTIONS LLC
EverGreen Case Management
Fortify Wyoming LLC
FRONT RANGE PERS
GARDEN SQUARE OF CASPER
GOLDEN HOUR SENIOR CITIZENS CENTER
GOSHEN CO. WY SENIOR FRIENDSHIP CTR
GREENER PATHS, INC
Hands 2 Help LLC
Healing Hearts Home Health
HIGH COUNTRY HEALTHWATCH
HOME STYLE DIRECT
HOMESTEAD ASSISTED LIVING
HOT SPRINGS CO SENIOR CTR
HUMBLE HORIZON HOME HEALTH LLC
Hyland Nursing Services, LCC
INDEPENDENT LIVING SYSTEMS, LLC
Integrity Home Care LLC
INTERMOUNTAIN HOME HEALTH
JENNIFER SCHUMACHER, LLC
JOHNSON COUNTY HEALTHCARE CENTER HOME HEALTH
KELLIE JENSEN COUNSELING & CASE MANAGEMENT
KEMMERER SENIOR CENTER
Kindred Souls of Wyoming LLC
LANDER SENIOR CENTER
LEGACY HOMES ASSISTED LIVING FACILITY
LESLIE'S CASE MANAGEMENT, LLC
LIFE LINK OF SHERIDAN COUNTY
LINDA TRUJILLO CASE MANAGEMENT
LIV HEALTH
MEADOW WIND ASSISTED LIVING FACILITY
MEALS ON WHEELS OF CHEYENNE
MEALS ON WHEELS OF NATRONA COUNTY
MOM'S MEALS
MOUNTAIN LODGE LLC
Nikki Green Advocacy & Consulting
NIOBRARA SENIOR CENTER INC
NORTH BIG HORN SENIOR CENTER
Oil City Case Management
PARK PLACE ASSISTED LIVING COMMUNITY
Phoenix Case Management
PINE BLUFFS SENIOR CENTER, INC
PREMIER HOME HEALTH
PREMIUM HEALTH AT HOME LLC, RAWLINS
PREMIUM HEALTH AT HOME, LARAMIE
PRIMROSE RETIREMENT COMMUNITY OF GILLETTE
QUALITY HOME CARE INC
Rebekah Vondenkamp/ IFS
RIVERTON SENIOR CITIZENS CENTER
ROBIN SEELEY CASE MANAGEMENT, LLC
ROCK SPRINGS YOUNG AT HEART
ROCKY MOUNTAIN HEALTHCARE ADVOCATES, INC
ROCKY MOUNTAIN HOME CARE
SALT RIVER CENTER/STAR VALLEY SENIOR CITIZENS INC
SENIOR ACTIVITY CENTER OF CAMPBELL COUNTY
SENIOR CENTER OF JACKSON HOLE
SENIOR CITIZEN'S COUNCIL
SENIOR CITIZENS AGO-GO
SERVICES FOR SENIORS, INC.
SHILOH CASE MANAGEMENT, LLC
Shoshoni Senior Center
SHOWBOAT RETIREMENT CENTER
SIERRA HILLS ASSISTED LIVING COMMUNITY
SPRING WIND ASSISTED LIVING COMMUNITY
SWEETWATER COMMUNITY NURSING
TEN SLEEP SENIOR CENTER, INC
TenderCare Home Health
UINTA HOME HEALTH
Valued Relationships, Inc.
Village Caregiving, LLC
WASHAKIE CO. SENIOR CITIZEN CTR.
WESTON COUNTY SENIOR SERVICES
WESTON COUNTY HEALTH SERVICES
WHOLE CASE MANAGEMENT
Wildflower Case Management, LLC
WILLOW CREEK HOMES OF EVANSTON
WILLOWCREEK HOMES OF BUFFALO
WIND CITY CASE MANAGEMENT, LLC
WYOMING ASSISTED LIVING LLC
Wyoming Home Health and Hospice-Big Horn INC DBA Eclipse Home Health
WYOMING INDEPENDENT LIVING, INC. (WIL)
WYOMING PIONEER HOME
WYOMING SERVICES FOR INDEPENDENT LIVING
Yellowstone ALF Operations LLC DBA Absaroka Senior Living
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If other, please specify:
Provider/ Staff Name
Provider/ Staff Phone
Did this incident occur while participating in remote support service?
Yes
No
Duty to Report
Adult Protection Services Act
Child Protection Services Act
Incident Description
Click for Definition
Incident Type
DFS Notification
Select
Incident Location
Suspected Abuse
Required
Home
Assisted Living Facility
Adult Day Care
Other
*
Suspected Self Abuse
Required
Home
Assisted Living Facility
Adult Day Care
Other
*
Suspected Neglect
Required
Home
Assisted Living Facility
Adult Day Care
Other
*
Suspected Self Neglect
Required
Home
Assisted Living Facility
Adult Day Care
Other
*
Suspected Exploitation
Required
Home
Assisted Living Facility
Adult Day Care
Other
*
Suspected Abandonment
Required
Home
Assisted Living Facility
Adult Day Care
Other
*
Death
Required
Home
Assisted Living Facility
Adult Day Care
Other
*
Intimidation
Required
Home
Assisted Living Facility
Adult Day Care
Other
*
Sexual Abuse
Required
Home
Assisted Living Facility
Adult Day Care
Other
*
Police Involvement
N/A
Home
Assisted Living Facility
Adult Day Care
Other
*
Crime Committed By Participant
N/A
Home
Assisted Living Facility
Adult Day Care
Other
*
Injuries Caused By Restraints
N/A
Home
Assisted Living Facility
Adult Day Care
Bathroom
Bedroom
Living Room
Kitchen
Common Room
Outside of Facility
Outside of Home
During Transport (vehicle)
Other
*
Serious Injury
N/A
Home
Assisted Living Facility
Adult Day Care
Bathroom
Bedroom
Living Room
Kitchen
Common Room
Outside of Facility
Outside of Home
During Transport (vehicle)
Other
*
Elopement
N/A
Home
Assisted Living Facility
Adult Day Care
Other
*
Medication Error
N/A
Home
Assisted Living Facility
Adult Day Care
Other
*
Use of Restraint
N/A
Home
Assisted Living Facility
Adult Day Care
Bathroom
Bedroom
Living Room
Kitchen
Common Room
Outside of Facility
Outside of Home
During Transport (vehicle)
Other
*
Medical/Behavioral Admission
N/A
Home
Assisted Living Facility
Adult Day Care
Other
*
Food Poisoning
N/A
Home
Assisted Living Facility
Adult Day Care
Other
*
Preceding Events
*
Description of Incident
*
Actions Taken
*
Notifications
Get DFS Contact Info
DFS Contact Information
Select Location
AFTON
BUFFALO
CASPER
CHEYENNE
CODY
DOUGLAS
EVANSTON
GILLETTE
GLENROCK
GREYBULL
JACKSON
KEMMERER
LANDER
LARAMIE
LUSK
LYMAN
NEWCASTLE
PINEDALE
POWELL
RAWLINS
RIVERTON
ROCK SPRINGS
SHERIDAN
SUNDANCE
THERMOPOLIS
TORRINGTON
WHEATLAND
WORLAND
*
Address
ZIP Code
Phone
Hours
Contact
Contact Name
Date Contacted
Contact Method
Department of Family Services
*
Phone
Fax
Internet/Email
InPerson
*
Protection and Advocacy
*
Phone
Fax
Internet/Email
InPerson
*
Division
*
Phone
Fax
Internet/Email
InPerson
*
Case Manager
*
Phone
Fax
Internet/Email
InPerson
*
Guardian/Representative/Power of Attorney
*
Phone
Fax
Internet/Email
InPerson
*
Law Enforcement Agency (if applicable)
*
Phone
Fax
Internet/Email
InPerson
*
Healthcare Licensure Survey
*
Phone
Fax
Internet/Email
InPerson
*
Medicaid Fraud
*
Phone
Fax
Internet/Email
InPerson
*
* Note: After you select "Submit" you will go to a Confirmation page where you will be able to Print the Incident Report.
Herschler Building, 122 W. 25th Street, 4 West, Cheyenne, WY 82002 E-Mail: alice.zimmerman@wyo.gov • WEB page: http://health.wyo.gov/healthcarefin/medicaid/homecareservices.html Toll Free Phone (866) 571-0944 • Fax: (307) 777-8685
Incident Description Location: Other
Please add "Other" location description of incident below:
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