Long-Term Care Facility Self-Reported Incidents

The Centers for Medicare and Medicaid Services requires long-term care facilities to self- report incidents occurring in their facilities to the Office of Inspector General. For your convenience, Long-Term Care Self-Reported incident forms are available to promote continuity and consistency.

Facility-Reported Incident​ Instructions

1. Complete every section of the Initial FRI Form.pdf
   
2. TheFollow Up FRI Form.pdf is now separate and must be completed within five (5) days.
   
3. If you choose to complete the form electronically, simply download and save the form to your computer. 
4. If there is insufficient space to complete an answer, additional pages may be used.
5. Attach all supporting documentation.
6. You may submit the forms and any attachments via email, mail or fax.
7. To determine the appropriate Division of Health Care Branch to which you should submit your paperwork, please see the Regional Map  and the corresponding Contact Information.
8. If you have any questions, please contact your Division of Health Care Branch Office. 

Long Term Care Regulations and Statutes

Note that the Legislative Research Commission (LRC) maintains Kentucky Administrative Regulations (KAR) and Kentucky Revised Statutes (KRS). Links to KARs and KRS can change. LRC maintains a website available to the public with a searchable database to access all active regulations and statutes.

Kentucky Revised Statutes  Search

Kentucky Administrative Regulations

Information for OIG Licensed Facility Types
​

Assisted ​Living Communities

• ​902 KAR 20:480 Assisted living communities​
  

Alzheimer's Nursing Home

• KRS 216B.020 Certificate of Need

• 902 KAR 20:291 Alzheimer's nursing homes

Family Care Homes

• 902 KAR 20:041 Operation and services

• KRS 216B.020 Certificate of Need

• 902 KAR 20:051 Operation and services
  

Intermediate Care Facility for Mental Retardation

• KRS 216B.020 Certificate of Need

• 902 KAR 20:086 Operation and service
  

Personal Care Homes

• KRS 216B.020 Certificate of Need
  

• 902 KAR 20:036 Operation and services
  

• PCH SMI Screening Form
  

Facility Specifications

           
Title 900
Cabinet for Health and Family Services
Department for Public Health
Chapter 2 Long-term Care

• 010 Access and hours of visitation 
• 020 Appeals
• 040 Citations and violations; criteria and specific acts 
• 050 Transfer and discharge rights 
• 060 Hearings concerning transfer and discharge rights

Chapter 6 Certificate of Need

• 040 Licensure hearings