Long Term Care Facility Self Reported Incidents

The Centers for Medicare and Medicaid Services (CMS) requires long term care facilities to self report incidents occurring within their facility to the Office of Inspector General.  For your convenience a Long Term Care Self-Reported incident Form was created by the Office of Inspector General. The use of this form is encouraged to promote continuity and consistency. Below are instructions on how to report such incidents.

General Instructions

1. Complete every section of the Self Reported Incident Form.
2. If there is insufficient space to complete an answer, additional pages may be used.
3. Attach all supporting documentation.
4. Call your Office of Inspector General (OIG) Division of Health Care Enforcement Branch Office if you have any questions or to submit your completed Self Reported Incident Form.

Northern Enforcement Branch
L & N Building, 10-W
908 West Broadway
Louisville, KY 40203
Phone:  (502) 595-4079
Fax:  (502) 595-4540

Southern Enforcement Branch
116 Commerce Avenue
London, KY 40744
Phone:  (606) 330-2030
Fax: (606) 330-2056

Eastern Enforcement Branch
P.O. Box 12250
455 Park Place
Lexington, KY 40511
Phone:  (859) 246-2301
Fax:  (859) 246-2307

Western Enforcement Branch
Western State Hospital
2400 Russellville Road
Hopkinsville, KY 42240
Phone:  (270) 889-6052
Fax:  (270) 889-6088 or (270) 889-6089

Detailed instructions.