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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.

Self Reported Incidents Instructions

General Instructions

  1. Complete every section of the Self Reported Incident Form.
  2. Please see the detailed instructions if you have any questions on how to complete the form.
  3. If you choose to complete electronically, simply open the form and save it 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 Self Reported Incident Form and any attachments via email, mail or fax.
  7. To determine the appropriate Division of Health Care Enforcement Branch to submit your paperwork to, please see Contact Information.
  8. If you have any questions, please contact your Division of Health Care Enforcement Branch Office. 


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Last Updated 10/23/2017