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 LME and to DHHS (see addresses below). Consumer deaths within 7 days of a consumer’s home restrictive intervention must be reported immediately. Providers have 72 hours to complete all other reports of restrictive intervention. Name(s) of Staff Conducting Intervention Current Certification CPR First Aid NCI CPI Other Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No STAFF Yes No Yes No Yes No Yes No Describe the debriefing with the individual and/or guardian: 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?) EVALUATION Yes No Has the Person-centered Planning or Child & Family Team previously addressed this issue? Does consumer have a crisis plan? Yes No Was the current plan effective in addressing this issue? Yes No Does consumer have a behavior plan? Yes No Was the current plan used prior to the intervention? Yes No Has the need for a crisis or behavior plan (or plan revision) been communicated to the service planning team? Yes No Describe plans for follow-up: Persons notified: Name Date Time Person-centered Planning Team Representative am pm Host LME am (specify) pm Legal Guardian am pm Other am (specify) pm
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 consumer’s 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. STAFF Name(s) of Staff Conducting Intervention Current Certification CPR First Aid NCI CPI Other Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No EVALUATION Describe the debriefing with the individual and/or guardian: 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?) Has the Person-centered Planning or Child & Family Team previously addressed this issue? Yes No Does consumer have a crisis plan? Yes No Was the current plan effective in addressing this issue? Yes No Does consumer have a behavior plan? Yes No Was the current plan used prior to the intervention? Yes No Has the need for a crisis or behavior plan (or plan revision) been communicated to the service planning team? Yes No Describe plans for follow-up: Persons notified: Name Date Time Person-centered Planning Team Representative am pm Host LME (specify) am pm Legal Guardian am pm Other (specify) am pm
qm04formrestinterventions11-04%20(2).docx