Provider Notice issued 10/21/2025

Incident Reporting Requirements for Supportive Living Program (SLP) Providers

This notice acts as a reminder for Supportive Living Program (SLP) providers to complete incident reports in a timely manner and in their entirety. Incident reporting is a state and federal requirement. 

What incidents are required to be reported?

Section 146.295(l) and 146.305 of the 89 Ill. Adm. Code requires the SLP to submit a preliminary incident report for any occurrence of an emergency requiring hospital service, police, fire department, or coroner.  The report must be sent to the Illinois Department of Healthcare and Family Services (HFS), Bureau of Long Term Care (BLTC), by fax within 24 hours after the occurrence.  

SLP incident reporting example requirements include, but are not limited to, the following:

• Abuse or suspected abuse of any nature by anyone including another resident, staff, volunteer, family, friend, etc.

• Allegations of theft

• Elopement of residents/missing residents

• Any crime involving residents

• Fire alarm activation that results in on-site response by local fire department personnel  

• Physical injury suffered by residents, especially during a mechanical failure or force of nature

• Loss of electrical power or other utility outages, including the emergency call system, in excess of one hour

• Evacuation of residents for any reason

How are incidents reported?

The designated incident report form should be completed for reportable incidents. The form must be submitted to HFS BLTC via fax (217-557-5061) withing 24 hours of occurrence. Final or updated incident reports should be faxed when new information is obtained. Any designated staff may submit an incident report.

What should be included on the incident report? 

The description of the incident should include pertinent information that occurred before, during, and after the incident. Be as specific as possible including first and last name(s) of any residents and/or staff involved along with specific dates and times (i.e. avoid using terms “yesterday”, 1 month ago, etc.). Every data field should be completed. If the field is not applicable to the incident, mark as “N/A”. 

Provide pertinent details about the incident including:

• Date, time, and location 

• All individuals involved (name(s), role, any available contact information) 

• Resident payor source: Medicaid, Private Pay, and MCO status (if applicable)

• Notify the MCO, if applicable.

• A detailed description of incident, noting any injuries and/or damages

• Actions taken (i.e. medical evaluation/treatment, law enforcement notification, physician notification, POA notification, IVD issued, etc.)

• Any updates or additional information since the incident should be added to the final incident report and faxed to HFS. 

• All incidents that involve a mechanical failure or natural force requiring hospital service, police, fire department or coroner are required to submit a final report (i.e. elevator outage, power/utility outage, storm damage, etc.). The final report should include how the emergency was handled, the final outcome, who was involved, and what steps are being taken to prevent the situation in the future, if applicable.

Incident Report Example:

“On 04/19/2025 at 11:15am, resident Jane Doe reported $50 missing from her apartment (apt 203). She stated she was missing 2- $20 bills and 1-$10 bill. Jane stated that she was in bed last night (4/18) and pulled her call light. CNA (MS) answered the call light and then CNA (BW) entered the apartment, too. CNA (MS) left the apartment, but CNA (BW) stayed. CNA (BW) assisted the resident to the bathroom with her walker and then back to her chair in the bedroom, without her walker. Jane stated that CNA (BW) went back into the bathroom and pushed her walker, turning it around. She then saw CNA (BW) reach into her purse and pull out her open wallet. Jane stated that she turned her head because she knew what was about to happen and did not want to witness it. When Jane’s daughter (her POA) came to visit this morning, she had her look in her purse and when they pulled the wallet from the purse, the wallet was zipped, and Jane never zips her wallet. She also noticed the missing $20 bills and the $10 bill. Camera footage reviewed and matched resident’s report. On 4/19 at 2:15pm, spoke with CNA (BW) who was suspended pending ongoing investigation. Internal investigation of residents and staff conducted without additional findings. At 3pm- North Pole Police Department notified- spoke with Officer Claus. At 3:30pm- Office Claus arrived at SLP- report given and Officer interviewed Jane and daughter. Resident chose not to press charges. Police Report #: P11-010203. POA onsite and aware.

Final Incident Report: As of 4/24/25, CNA (BW) remained suspended and on 4/25/25, CNA (BW) was terminated from North Pole Supported Living after admitting to the theft and returning to the SLP with $50 for Jane.” 

Questions regarding this notice may be directed to the SLP inbox at HFS.SLF@illinois.gov .  

Laura Phelan, Administrator 
Division of Medical Programs