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LIC 624: Unusual Incident/Injury Report

By Sevana Care · Checked against cdss.ca.gov and Title 22 on

When it is due
A written report within seven days [3].Known or suspected physical abuse, abandonment, abduction, isolation, financial abuse or neglect in a long-term care facility, which an RCFE is [12], has a separate clock under Welfare and Institutions Code § 15630 [5]. Call law enforcement at once, two hours at most, and send a written report within 24 hours [5]. When the abuse was allegedly caused by another resident with dementia diagnosed by a licensed physician and there was no serious bodily injury, that clause asks for the written report within 24 hours and does not mention a call [5].
Who fills it out
The licensee must send the report to licensing [3].The form has a "Report submitted by" line and a "Report reviewed/approved by" line, each with a name, title and date [1].
Where it is kept
A copy goes in the resident's file.The form says "Retain copy of report in client's file" [1], and CDSS lists it among resident records [2].
How long to keep
§ 87506 does not list incident reports by name [4].It requires resident records to be kept at least three years after service ends [4]. CDSS lists this report under resident records [2].

LIC 624 is the California Department of Social Services (CDSS) form for reporting an unusual incident or injury to a resident. In an RCFE, Title 22 § 87211 requires a written report to licensing and to the person responsible for the resident within seven days of a death; a serious injury, as determined by the attending physician, while the resident is under facility supervision; the use of an automated external defibrillator (AED); or an incident that threatens a resident's welfare, safety or health [3]. LIC 624 is on CDSS's list of records an RCFE keeps [2].

Who fills it out

The licensee must send the report to licensing: "Each licensee shall furnish to the licensing agency such reports as the Department may require" [3]. The form has a "Report submitted by" line and a "Report reviewed/approved by" line, each with a name, title and date. There is also a box for "Licensee/supervisor comments" [1].

The rule lists four events that need the seven-day written report [3]:

  • the death of any resident, from any cause, wherever it happened
  • a serious injury, as determined by the attending physician, while the resident is under facility supervision
  • the use of an Automated External Defibrillator
  • any incident that threatens the welfare, safety or health of a resident, such as psychological abuse of a resident by staff or other residents, or an unexplained absence

For a death, CDSS lists a separate form, LIC 624A, the Death Report [2][7].

The form is a general Community Care Licensing Division form. Its header reads "California Department of Social Services, Community Care Licensing Division," it says "clients/residents," and it never names RCFEs [1].

The report goes to the licensing agency and to the person responsible for the resident [3]. The form has lines to record who was told: licensing, Adult/Child Protective Services, the long-term care ombudsman, the parent, guardian or conservator, law enforcement, and the placement agency, each with a name and phone number [1].

When it is due

Written report: seven days. Send it to licensing and to the person responsible for the resident within seven days of the occurrence [3]. The rule says "seven days" and does not say business days [3].

The form's own header also says to notify the licensing agency, the placement agency and responsible persons "by next working day," and to submit the written report within 7 days of occurrence [1]. Title 22 § 87211 gives RCFEs the seven-day written report for these four events [3].

Other deadlines in § 87211 [3]:

  • Epidemic outbreaks, poisonings, catastrophes or major accidents that threaten residents, staff or visitors: within 24 hours, by telephone or fax, to licensing and, when appropriate, to the local health officer. Example: an event at 8 pm Saturday must be reported by 8 pm Sunday.
  • Fires or explosions on the premises: immediately to the local fire authority, and no later than the next working day to licensing. Where there is no organized fire service, within 24 hours to the State Fire Marshal.
Note

Suspected abuse of an elder is a separate clock. Title 22 § 87211(b) and (c) send you to Welfare and Institutions Code § 15630(b)(1) [3]. Section 87211(c) itself covers "all other instances" of elder abuse and lists no types [3]. Section 15630(b)(1) covers physical abuse, abandonment, abduction, isolation, financial abuse and neglect [5].

Section 87211(a)(1)(D) names psychological abuse by staff or other residents as a seven-day-report event [3]. The § 15630(b)(1) list does not use the word "psychological" [5]. An RCFE is a long-term care facility under WIC § 15610.47(e) [12].

For abuse in a long-term care facility, § 15630(b)(1)(A) requires a verbal report to local law enforcement immediately or as soon as practically possible, and no later than two hours, except in one dementia case. It also requires a written report within 24 hours to the long-term care ombudsman, local law enforcement and the state licensing agency [5].

Example: for physical abuse seen at 2 pm, call law enforcement right away and by 4 pm at the latest, and send the written reports by 2 pm the next day. The dementia case: when the alleged abuser is another resident with dementia diagnosed by a licensed physician and there was no serious bodily injury, there is no two-hour call, and the written report within 24 hours goes to the ombudsman and law enforcement only [5]. The clock starts when the reporter observes, learns of or suspects the abuse [5].

Where it is kept

The form says "Retain copy of report in client's file" [1]. CDSS lists the unusual incident/injury report and the death report under "Residents Records," records that "must be kept in the facility complete and current, and readily available for review" [2].

Title 22 § 87506 requires a record for each resident, kept "in the facility or in a central administrative location readily available to facility staff and to licensing agency staff" [4]. Records are kept for a minimum of three years after service to the resident ends [4]. The section does not list incident reports by name [4].

What the record must show

  • The contents. § 87211(a)(1) lists what it must contain: the resident's name, age, sex and date of admission; the date and nature of the event; the attending physician's name, findings and treatment, if any; and what happened to the case [3]. The form has fields for the resident, age, sex, admission date, description, physician, treatment, follow-up and action taken or planned [1].
  • Who was notified, and the dates. The form asks who was notified, with name and phone number, and has the date it occurred and the date of the report [1]. The seven days count from the occurrence [3].

The CDSS inspection checklist. The checklist for RCFEs (LIC 9123) starts "Review Regional Office (RO) facility file prior to inspection" and lists "Facility Complaint and Incident Reports (minimum three (3) years)" [6].

Its RO column marks items checked at the regional office, and its FAC column marks items that need follow-up at the facility [6].

Other forms with "624" in the number

From the CDSS forms list [10]:

  • LIC 624A (7/99), Death Report: for the death of a client from any cause, wherever it occurred [7].
  • LIC 624B (8/08), Unusual Incident/Injury Report - Family Child Care Home: for family child care homes [8].
  • LIC 624 LE (12/22), Law Enforcement Contact Report: for incidents where law enforcement contacts a child in a group home or similar children's program. Its check boxes list group homes, short-term residential therapeutic programs, community treatment facilities and similar programs, not RCFEs [9].

Questions

Do RCFEs use LIC 624?

CDSS lists "Unusual Incident/Injury/Report (LIC 624)" and "Death Report (LIC 624A)" in its records list for residential care facilities for the elderly [2]. Title 22 § 87211 sets the report's contents and its seven-day deadline and does not name the form [3].

Is a death reported on LIC 624?

CDSS lists a separate Death Report, LIC 624A. Its header reads: "Licensee must report the death of a client of any cause, regardless of where the death occurred" [7]. Title 22 § 87211(a)(1)(A) puts a death under the same seven-day written report [3].

Does LIC 624 cover suspected abuse?

LIC 624 has boxes for alleged abuse [1]. For physical abuse, abandonment, abduction, isolation, financial abuse and neglect, though, Welfare and Institutions Code § 15630(b)(1) sets who must be told and how fast [5]. Except in the dementia case, that is a verbal report to law enforcement within two hours and a written report within 24 hours to the ombudsman, law enforcement and licensing. In the dementia case there is no two-hour call, and the 24-hour written report goes to the ombudsman and law enforcement [5]. Psychological abuse is a seven-day-report event under § 87211(a)(1)(D) [3]. CDSS lists SOC 341, Report of Suspected Dependent Adult/Elder Abuse, as a mandated reporter form [11].

How Sevana Care keeps this record

Who has to hear about it, and by when? You log the incident once in Sevana Care. For a death, a serious injury or an elopement (left without supervision), the checklist lists who to tell and shows the seven-day written report with its due time. It ticks when marked sent and flags Overdue if the deadline passes. We don't fill out or file the LIC 624. Keep your filed copy on the resident's record. See the Incidents tab in the sample home.

More in Medication, incident reports and safety plans

  • LIC 624A: The report you file when a resident dies
  • SOC 341: The report you file when you suspect abuse of a resident
  • LIC 610E: The disaster plan form for RCFEs and what the law requires in it
  • LIC 9282: The CDSS form for an RCFE's written infection control plan

Sources

  1. CDSS, LIC 624 (4/99), Unusual Incident/Injury Report (PDF)
  2. CDSS, LIC 311F (4/05), Records To Be Maintained At The Facility, Residential Care Facility For The Elderly (PDF)
  3. California Code of Regulations, Title 22, § 87211, Reporting Requirements (Westlaw)
  4. California Code of Regulations, Title 22, § 87506, Resident Records (Westlaw)
  5. Welfare and Institutions Code § 15630 (leginfo.legislature.ca.gov)
  6. CDSS, LIC 9123 (2/20), Facility Inspection Checklist, Residential Care Facility For The Elderly (PDF)
  7. CDSS, LIC 624A (7/99), Death Report (PDF)
  8. CDSS, LIC 624B (8/08), Unusual Incident/Injury Report - Family Child Care Home (PDF)
  9. CDSS, LIC 624 LE (12/22), Law Enforcement Contact Report (PDF)
  10. CDSS, Forms and Publications (I-L)
  11. CDSS, Public Information and Policies, Senior Care Licensing (lists SOC 341)
  12. Welfare and Institutions Code § 15610.47, "Long-term care facility" (leginfo.legislature.ca.gov)