ࡱ> q  rWbjbjt+t+ .AA-],,,,8d,3$. 4NT1$"&"&"&"&"&"&"$a%U'lJ"J"F$",,$"s6(!$"4`}%,,#" FORMTEXT        FORMTEXT        FORMTEXT     -  FORMTEXT    -  FORMTEXT      Provider Agency Name Consumer s Name Consumer s Social Security No.This form is used to report use of restrictive interventions for persons receiving publicly funded mental health, developmental disabilities and/or substance abuse (MH/DD/SA) services. Facilities licensed under G.S. 122C and unlicensed providers of community-based MH/DD/SA services must submit this form or a form with comparable information to the Local Management Entity (LME) responsible for the geographic area in which the service is provided. Failure to submit this report, as required by NC Administrative Code 10A NCAC 27E .0104 and 10A NCAC 27G .0600, may result in administrative actions being taken against the providers license and/or authorization to receive public funding. This form may also be used for internal documentation of interventions, if required by provider policies or LME contract. Instructions: Complete and submit this form to the local and/or state agencies responsible for oversight within 72 hours to report any restrictive intervention that (1) is administered inappropriately, (2) results in death, injury, discomfort or complaint or (3) is used in an emergency (not included in service plan). ( If requested information is unavailable, provide an explanation on the form and report the additional information as soon as possible. ( NOTE: All use of restrictive intervention, including planned use that is administered appropriately without discomfort or complaint and unplanned emergency use, must be documented in the consumer record, as required by NC Administrative Code 10A NCAC 27E .0104. Page 1-2 Instructions: The direct care staff person who is most knowledgeable about the intervention should complete pages 1-2 of this form as soon as possible and submit to the unit supervisor for review.INTERVENTION DETAILSDate of intervention:  FORMTEXT       Time:  FORMTEXT        FORMCHECKBOX  a.m.  FORMCHECKBOX  p.m. Consumer s Home LME:  FORMTEXT       Facility:  FORMTEXT       Intervention Type Duration (Number in order of use) Hours Minutes  FORMTEXT   Isolation  FORMTEXT     FORMTEXT     FORMTEXT   Seclusion  FORMTEXT     FORMTEXT     FORMTEXT   Restraint Standing  FORMTEXT     FORMTEXT     FORMTEXT   Restraint Sitting  FORMTEXT     FORMTEXT     FORMTEXT   Restraint Face Down  FORMTEXT     FORMTEXT    Intervention Specifics: (Check all that apply)  FORMCHECKBOX  NCI  FORMCHECKBOX  CPI  FORMCHECKBOX  Other  FORMTEXT       If over 15 minutes, who authorized the additional time? Name  FORMTEXT       Title  FORMTEXT       Number of restrictive interventions in last 30 days:  FORMTEXT     Purpose of the intervention (check all that apply):  FORMCHECKBOX  Prevent harm to self  FORMCHECKBOX  Prevent harm to others  FORMCHECKBOX  Prevent serious property damage  FORMCHECKBOX  Planned intervention (Person-Centered Plan date:  FORMTEXT       ) If planned, was intervention reviewed & approved by a Client Rights or Restrictive Intervention Committee prior to the intervention?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Agency:  FORMTEXT       Committee:  FORMTEXT       Date:  FORMTEXT       DESCRIPTIONBriefly describe what happened to cause a restrictive intervention, including specifics of the individual s behavior (e.g. frequency, intensity, duration), and actions leading to the behavior. Be specific. (Attach sheets if needed)  FORMTEXT      Positive and/or less restrictive interventions attempted (check all that apply):  FORMCHECKBOX  Verbal Redirection  FORMCHECKBOX  Distractions (e.g. take a walk)  FORMCHECKBOX  Impromptu treatment session  FORMCHECKBOX  Removing consumer from situation (verbal and physical prompts)  FORMCHECKBOX  Separation from group (verbal and physical prompts)  FORMCHECKBOX  Other  FORMTEXT       Description of results:  FORMTEXT      Rationale for using restrictive of intervention (Be specific):  FORMTEXT      HEALTH STATUSSignificant medical conditions identified previously:  FORMCHECKBOX  None  FORMCHECKBOX  Heart Condition  FORMCHECKBOX  Physical disabilities  FORMCHECKBOX  High Blood Pressure  FORMCHECKBOX  Asthma  FORMCHECKBOX  Other (specify):  FORMTEXT       Medications:  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        HEALTH STATUS INFORMATIONITEMINITIAL CHECK (Prior to Intervention)ENDING CHECK (Immediately after Intervention)FOLLOW-UP CHECK (30 minutes after Intervention)Consciousness Please explain any abnormality:  FORMCHECKBOX  Alert  FORMCHECKBOX  Dazed  FORMTEXT       FORMCHECKBOX  Alert  FORMCHECKBOX  Dazed  FORMCHECKBOX  Unconscious  FORMTEXT       FORMCHECKBOX  Alert  FORMCHECKBOX  Dazed  FORMCHECKBOX  Unconscious  FORMTEXT      Speech Please explain any abnormality: FORMCHECKBOX  Normal  FORMCHECKBOX  Abnormal  FORMTEXT       FORMCHECKBOX  Normal  FORMCHECKBOX  Abnormal  FORMTEXT       FORMCHECKBOX  Normal  FORMCHECKBOX  Abnormal  FORMTEXT      Breathing Please explain any abnormality: FORMCHECKBOX  Normal  FORMCHECKBOX  Hard / Irregular  FORMTEXT       FORMCHECKBOX  Normal  FORMCHECKBOX  Hard / Irregular  FORMTEXT       FORMCHECKBOX  Normal  FORMCHECKBOX  Hard / Irregular  FORMTEXT      Movement Please explain any abnormality: FORMCHECKBOX  Normal  FORMCHECKBOX  Abnormal  FORMTEXT       FORMCHECKBOX  Normal  FORMCHECKBOX  Abnormal  FORMTEXT       FORMCHECKBOX  Normal  FORMCHECKBOX  Abnormal  FORMTEXT      Skin Color Please explain any abnormality: FORMCHECKBOX  Normal  FORMCHECKBOX  Pale  FORMCHECKBOX  Flushed  FORMTEXT       FORMCHECKBOX  Normal  FORMCHECKBOX  Pale  FORMCHECKBOX  Flushed  FORMTEXT       FORMCHECKBOX  Normal  FORMCHECKBOX  Pale  FORMCHECKBOX  Flushed  FORMTEXT      Orientation Please explain any abnormality: FORMCHECKBOX  Person  FORMCHECKBOX  Place  FORMCHECKBOX  Time  FORMTEXT       FORMCHECKBOX  Person  FORMCHECKBOX  Place  FORMCHECKBOX  Time  FORMTEXT       FORMCHECKBOX  Person  FORMCHECKBOX  Place  FORMCHECKBOX  Time  FORMTEXT      Affect / Mood Please explain any abnormality: FORMCHECKBOX  Appropriate  FORMCHECKBOX  Inappropriate  FORMTEXT       FORMCHECKBOX  Appropriate  FORMCHECKBOX  Inappropriate  FORMTEXT       FORMCHECKBOX  Appropriate  FORMCHECKBOX  Inappropriate  FORMTEXT      Describe the person s behavior after the intervention:  FORMTEXT      MONITORINGWas the person monitored continuously during the intervention and for 30 minutes afterward?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If not monitored continuously, provide an explanation:  FORMTEXT      Name/Title of persons providing monitoring (Please print):  FORMTEXT       Signature: Date  FORMTEXT        FORMTEXT       Signature: Date  FORMTEXT       Name/Title of staff person documenting intervention (Please print):  FORMTEXT       Signature: Date  FORMTEXT        Page 3 Instructions: The supervisor of the service should review pages 1-2 of this form, complete page 3 and submit to the LME responsible for the geographic area in which the service is provided. If a consumer dies or is permanently impaired as a result of the intervention, this report must also be submitted to the consumers home LME and to DHHS (see addresses below). Consumer deaths within 7 days of a restrictive intervention must be reported immediately. Providers have 72 hours to complete all other reports of restrictive intervention. STAFFName(s) of Staff Conducting Intervention Current Certification CPR First Aid NCI CPI Other  FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMTEXT        FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMTEXT        FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMTEXT       EVALUATIONDescribe the debriefing with the individual and/or guardian:  FORMTEXT      Describe the debriefing with staff: (What could have been done differently to avoid the need for restrictive intervention in this situation? What can be done to reduce the need for future restrictive interventions?)  FORMTEXT      Has the Person-centered Planning or Child & Family Team previously addressed this issue?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Does consumer have a crisis plan?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Was the current plan effective in addressing this issue?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Does consumer have a behavior plan?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Was the current plan used prior to the intervention?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Has the need for a crisis or behavior plan (or plan revision) been communicated to the service planning team?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoDescribe plans for follow-up:  FORMTEXT      Persons notified: Name Date Time Person-centered Planning Team Representative  FORMTEXT        FORMTEXT        FORMTEXT        FORMCHECKBOX am  FORMCHECKBOX  pm Host LME (specify)  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMCHECKBOX am  FORMCHECKBOX  pm Legal Guardian  FORMTEXT        FORMTEXT        FORMTEXT        FORMCHECKBOX am  FORMCHECKBOX  pm Other (specify)  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMCHECKBOX am  FORMCHECKBOX  pmName/Title of Staff Completing Form  FORMTEXT       Signature: Date  FORMTEXT       Name/Title of Supervisor  FORMTEXT       Signature: Date  FORMTEXT       Name/Title of Program Director  FORMTEXT       Signature: Date  FORMTEXT        Page 4 Instructions: This page is available for the provider agency or any agencies receiving the report to use for internal tracking and follow-up purposes. Leave this page blank when sending a report to the LME and/or other agencies..  RESTRICTIVE INTERVENTION FOLLOW-UP (for internal use only)Report Receipt Date:  FORMTEXT       INTERNAL USE ONLYCurrent Consumer Status:  FORMTEXT      LME s (or Other Oversight Agency s) Response:  FORMTEXT      Name/title of follow-up staff person (Please print):  FORMTEXT       Phone (  FORMTEXT     )  FORMTEXT       Signature ________________________________________________________ Date  FORMTEXT       Time  FORMTEXT        FORMCHECKBOX  a.m.  FORMCHECKBOX  p.m.INTERNAL USE ONLYNotes:  FORMTEXT       North Carolina Department of Health & Human Services  Division of Mental Health/Developmental Disabilities/Substance Abuse Services CONFIDENTIAL DHHS Restrictive Intervention Details Report CONFIDENTIAL PAGE  Confidentiality of consumer information is protected under Federal regulations, 42 CFR Part 2 and HIPAA, 45 CFR Parts 160 & 164. 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