(b) The documentation for critical incidents shall contain, minimally:

1. (1) The facility name and the name and signature of the person or persons reporting the incident;
2. (2) The name of the beneficiary or beneficiaries, staff person or persons, or others involved in the incident;
3. (3) The time, place, and date the incident occurred;
4. (4) The time and date the incident was reported and the name of the person within the facility to whom it was reported;
5. (5) A description of the incident;

6. (6)

   1. (A) The severity of each injury, if applicable.
   2. (B) Severity shall be indicated as follows:

(i) No offsite medical care required or first-aid care administered onsite;

1. (ii) Medical care by a physician or nurse or follow-up attention required; or

   1. (iii) Hospitalization or immediate offsite medical attention was required; and

2. (7) The resolution or action taken, date the action was taken, and the signature of the residential community reintegration program director.

   1. (c) The residential community reintegration program shall report those critical incidents to the Department of Human Services that include critical incidents requiring medical care by a physician or nurse or follow-up attention and incidents requiring hospitalization or immediate offsite medical attention shall be delivered via fax or mail to DHS Provider Certification within twenty-four (24) hours of the incident being documented.

      1. (d) The residential community reintegration program shall document and monitor internally, with a quality assurance and improvement process that will be made available for review and/or audit by an appropriate agency the following: critical incidents requiring medical care by a physician or nurse or follow-up attention and incidents requiring hospitalization or immediate offsite medical attention.