- Incident Database User Access Request Form – Healthcare facilities submit incident reports online to Healthcare Licensing and Surveys (HLS). HLS will investigate the occurrence and determine if appropriate facility action has been taken. Health surveyors also review incident reports prior to conducting annual surveys in facilities, and prior to reissuing a facility’s license. Reports may also be reviewed as part of a complaint investigation.
- Incident Database User Guide
- Report an Incident Here
- Nursing home reporting requirements: Federal Requirements for Alleged Violations of Mistreatment, Neglect, and Abuse, including Injuries of Unknown Source and Misappropriation of Resident Property.
- HLS/CNA-105 – Form used to report allegations of abuse, neglect, or misappropriation of resident property by Certified Nurse Aides in nursing care facilities and swing beds. This form is completed in addition to the online Incident Report form.
- Fire/Explosion/Life Safety Code-Incident/Accident Report form
- Reporting of Hospital Death Associated with Restraint or Seclusion
S&C: 14-27-Hospital-CAH/DPU – Memorandum re Hospital Restraint/Seclusion Deaths to be Reported Using the Centers for Medicare and Medicaid Services Form CMS-10455 (memo dated 05/09/14)
WDSC-RO8-1c – Memorandum providing clarification to hospitals regarding the reporting of Restraint/Seclusion Deaths (memo dated 03/08/17)
Reporting Form CMS-10455 (11/13)
Healthcare Licensing and Surveys
Healthcare Licensing and Surveys (HLS) assures that residents and patients receive quality care from healthcare facilities required to be licensed by the State of Wyoming. HLS also promotes health and safety through on-site inspections and complaint investigations.
2300 Capitol Avenue, Suite 510
Cheyenne, WY 82002
Fax: (307) 777-7127