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Printed: 06/20/2024 Form Approved OMB No. 09380391Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION
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How to fill out level of harm

01
Identify the type of harm being assessed (physical, emotional, financial, etc.)
02
Determine the severity of the harm on a scale (e.g. mild, moderate, severe)
03
Consider the impact of the harm on the individual or community
04
Make sure to assess the level of harm objectively and without bias
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Record and document your findings accurately

Who needs level of harm?

01
Individuals or organizations involved in risk assessment and management
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Policy makers and regulatory bodies
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Law enforcement agencies and legal professionals
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Level of harm refers to the severity of an incident or event that has impacted health, safety, or the environment, typically categorized into ranges from minimal to severe.
Entities that are subject to regulatory oversight, including healthcare providers, organizations handling hazardous materials, and other relevant entities are required to file level of harm.
To fill out level of harm, the reporting entity must provide detailed information about the incident, including the nature of the harm, affected parties, circumstances of the occurrence, and remedial actions taken.
The purpose of level of harm is to assess and communicate the impact of incidents, enabling appropriate regulatory responses, preventive measures, and accountability.
Information that must be reported includes the date and time of the incident, description of the harm, parties involved, immediate actions taken, and any subsequent mitigation efforts.
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