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Incident Reporting by Wyoming Healthcare Facilities

Attention Nursing Homes:  Federal Reporting Requirements for Alleged Violations of Mistreatment, Neglect, and Abuse, including Injuries of Unknown Source and Misappropriation of Resident Property: CMS S&C-05-09

When an incident report is received, Healthcare Licensing and Surveys (HLS) will investigate the occurrence and determine if appropriate facility action has been taken.  HLS health surveyors also review incident reports prior to conducting annual surveys in facilities, and prior to reissuing a facility’s license. Incident reports may also be reviewed as part of a complaint investigation.

Incident Report Form:  Word   PDF Format
Submit the completed incident report form by faxing and mailing.  The fax number and mailing address are provided on the form.  To protect patient/resident confidentiality, please do not e-mail the Incident Report form.

For Reporting and Investigating Allegations of Abuse, Neglect, or Misappropriation of Resident Property by Certified Nurse Aides in Nursing Care Facilities and Swing Beds, please note that a checklist (HLS/CNA-105 form) must be completed-in addition to the Incident Report Form:  Word Format   PDF Format

   Fire/Explosion/Life Safety Code Incident/Accident Report: (HLS/Con-120):   Word Format    PDF Format

Reportable Diseases and Conditions
- Healthcare facilities are required to report Reportable Diseases and Conditions to the Wyoming Department of Health, Epidemiology Section.  Those conditions classified as nosocomial (where two or more persons, either residents or employees, are affected) shall be reported immediately to the State Health Officer, the County Health Officer, and to Healthcare Licensing and Surveys.