Attention Nursing Homes: Federal Reporting Requirements for Alleged Violations of Mistreatment, Neglect, and Abuse, including Injuries of Unknown Source and Misappropriation of Resident Property:
When an incident report is received, the 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.
Word PDF Format
Incident Report Form:
To submit the information requested on this form:
• speak to a health surveyor by calling (307) 777-7123; or
• submit the completed form in hard-copy format by fax or by mail
(fax number/mailing address are provided on the report form)
• To protect patient/resident confidentiality, please do not e-mail the Incident Report form.
CNA-105 - Facility Checklist for Reporting and Investigating Allegations of Abuse, Neglect, or Misappropriation of Resident Property by Certified Nurse Aides in Nursing Care Facilities and Swing Beds (HLS/CNA-105) - please note that this checklist must be completed, in addition to the Incident Report Form: Word Format PDF Format
Fire/Explosion/Life Safety Code - Incident/Accident Report Form:
Word 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.