Confidential Dhhs Restrictive Intervention Details Report - North Carolina
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4North Carolina Department of Health & Human Services – Division of Mental Health/Developmental Disabilities/Substance Abuse Services
DHHS Restrictive Intervention Details Report
CONFIDENTIAL
CONFIDENTIAL
-
-
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 provider’s 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.
Date of intervention:
Time:
a.m.
p.m. Consumer’s Home LME:
Facility:
Intervention Type
Duration
Intervention Specifics:
If over 15 minutes, who authorized the additional time?
Hours
Minutes
(Number in order of use)
(Check all that apply)
Name
Isolation
NCI
Seclusion
Title
CPI
Restraint–Standing
Other
Number of restrictive interventions in last 30 days:
Restraint–Sitting
Restraint–Face Down
Purpose of the intervention (check all that apply):
Prevent harm to self
Prevent harm to others
Prevent serious property damage
Planned intervention (Person-Centered Plan date:
)
If planned, was intervention reviewed & approved by a Client Rights or Restrictive Intervention Committee prior to the intervention?
Yes
No
Agency:
Committee:
Date:
Briefly 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)
Positive and/or less restrictive interventions attempted (check all that apply):
Verbal Redirection
Distractions (e.g. take a walk)
Impromptu treatment session
Removing consumer from situation (verbal and physical prompts)
Separation from group (verbal and physical prompts)
Other
Description of results:
Rationale for using restrictive of intervention (Be specific):
Significant medical conditions identified previously:
Medications:
None
Heart Condition
Physical disabilities
High Blood Pressure
Asthma
Other (specify):
Confidentiality of consumer information is protected under Federal regulations, 42 CFR Part 2 and HIPAA, 45 CFR Parts 160 & 164.
DMH/DD/SAS-Community Policy Management Section – Form QM04
Effective October, 2004 – Rev. 11/18/04
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