Seclusion and , Restraint, and Emergency Safety Response Reporting Form

/ AHCCCS Medical Policy Manual
Chapter 900 –Quality management and Performance Improvement Program

AMPM Policy 962, Exhibit 962-1 Seclusion and Restraint Individual Reporting FormADHS/DBHS Form 1702.Exhibit 960-13

Seclusion and , Restraint, and Emergency Safety Response Reporting Form

Exhibit 9620-31 , Seclusion and Restraint Individual Reporting Form

All AHCCCS or state licensed facilities and programs, including out-of-state facilities, authorized to use seclusion, and restraint [1]with members must report each instance. Authorized providers may submit this information to AHCCCS using one of the following methods:

[2]A locally developed form that, at a minimum, captures all the reporting requirements identified in this attachment.

1.A flat file pulled from the Electronic Health Record (EHR) that, at a minimum, captures all the reporting requirements identified in this attachment.

Instructions: Completed forms should be sent to the T/RBHA Contractor or TRBHA with which the facility is subcontracted within five days of the occurrence. A form must be completed for each member secluded or, restrained., or requiring an emergency safety response.

Provider Information

Provider Information
Report Date: / Program/Facility License #: Click here to enter text.
AHCCCS Provider ID: Click here to enter text. / Program/Facility Name: Click here to enter text.
Contact Person Phone #:Click here to enter text. / Provider Address: Click here to enter text.
Contact Person & Title: Click here to enter text.
Name/Credentials/Title of Person Authorizing the Event: Click here to enter text.
Name/Credentials/Title of Person Re-Authorizing the Event: Click here to enter text.

Member Information

Member Information
Demographics
Member Name(Last, First, M.I.):Click here to enter text.
Date of Birth: / Age: / GenderSex:
CIS ID: Click here to enter text. / AHCCCS ID: Click here to enter text.
TXIX/XXI Eligible: ☐ Yes ☐ No / Member Behavioral Health Category: Click here to enter text. Select OneSMIGMH/SAChildSelect OneSMIGMH/SAChild
DDD: Click here to enter text. / CMDP: Click here to enter text.
CRSDDD: Click here to enter text. / ALTCS E/PDCMDP: Click here to enter text.
Name of member’s legal guardian (if applicable): Click here to enter text.
Phone number of member’s legal guardian (if applicable):Click here to enter text.
Other:Other:
Current Diagnoses
Code / Name
Current Scheduled Medications
Medication / Dosage / Frequency / Method of Administration

Event Information

If an Emergency Safety Response (ESR) occurs, then complete the “Personal Restraint” section below.[3] If a Seclusion and/or Restraintoccursoccur, complete all that apply. If the member is secluded and/or restrained, complete BOTH the seclusion and restraint sections.

Event Information

Type of Event:

/  ESR ☐Seclusion☐Restraint Restraint
Date: / Time (24-hour clock): / Evaluation/Initial face to face Assessment:

Did Member have medical condition(s) that placed them at greater risk for poor outcomes?

/ ☐ Yes, describe:
☐ No

Was the reason for restraint/seclusion and the conditions for release explained to the member?

/ ☐ Yes, describe:
☐ No

De-escalation Methods And All Less Restrictive Measures Attempted

Select de-escalation methods and all less restrictive measures attempted prior to seclusion and/or/ restraint: / ☐ Removing member from stimuli
☐ Encouraging member to express feelings in appropriate manner
☐ Conflict resolution
☐ Re-directing the member
☐ Offering prn medication, when necessary
☐ Allowing member to pace and vent
☐ Other (i.e. humor, distraction, 1:1, snack, etc.)

Restraint

Personal Restraint (Restraint (check box) Mechanical Restraint (check box)(Required for Emergency Safety Response)

Date of Administration: Click here to enter text.

Type of Restraint (i.e. Physical Hold):Click here to enter text.
Time (24-hour clock):Click here to enter text. Start time: Click here to enter text. End time: Click here to enter text.
Duration of Restraint: Click here to enter text. hoursHours Click here to enter text. / minutes
Name/Credentials/Title of Primary Person involved in the Restraint: Click here to enter text.

Mechanical Restraint (check box)Mechanical Restraint

Date of Administration: Click here to enter text.Date of Administration:

Type of Restraint:Click here to enter text.Time (24-hour clock): Start time: End time:
Time (24-hour clock):Click here to enter text. Start time: Click here to enter text. End time: Click here to enter text.Duration of Restraint: hours / minutes
Duration of Restraint: Click here to enter text. Hours Click here to enter text. minutesName/Credentials/Title of Primary Person involved in the Restraint:
Name/Credentials/Title of Primary Person involved in the Restraint: Click here to enter text.
Drug or [4]Medication used as Restraint
Date of Administration / Time of Administration / Medication / Dosage / Frequency / Method of Administration

Seclusion

Date of Administration: Click here to enter text.

Time (24-hour clock): Click here to enter text. Start time: Click here to enter text. End time: Click here to enter text.
Duration of Restraint: Click here to enter text. hours/ Click here to enter text. minutes
Name/Credentials/Title of Primary Person involved in the Restraint: Click here to enter text.

De-escalation Methods and all Less Restrictive Measures

Select de-escalation methods and all less restrictive measures attempted prior to seclusion/ restraint: /  Removing member from stimuli
 Encouraging member to express feelings in appropriate manner
 Conflict resolution
 Re-directing the member
 Offering prescription medication, when necessary
 Allowing member to pace and vent
 Other (i.e. humor, distraction, 1:1, snack, etc.)

Reason for Restraint and/or Seclusion

Reason for Restraint/Seclusion

Include relevant informationto describe facts/behaviors prior to the emergency safety situation and specific facts/behaviors justifyingtheuseofseclusion or restraint. Be descriptive(i.e.,‘hittingand kickingstaff’ insteadof‘physically aggressive toward staff’).
☐ Danger to Self (DTS) / Member Behaviors: Click here to enter text.
Member Quotes: Click here to enter text.
☐ Danger to Others (DTO) / Member Behaviors: Click here to enter text.
Member Quotes: Click here to enter text.
Member Quotes:

Monitoring

Monitoring
The member must be checked personally examined at a minimum of every 15 minutes to ensure the behavioral health member’s comfort and safety and determining the client’s need for food, fluid, bathing and access to the toilet. The member must be checked every 5 minutes if he/shethe member has a medical condition that places him/her at a greater risk, as determined by the facility, by the restraint and/or seclusion. Attach internal documentation of face-to-face monitoring for all episodes that require such documentationperA.A.C.R9-21-204, A.A.C.R9-10-225orA.A.C.R9-10-226. Addendum content must include requirements contained in ADHS/DBHSAHCCCS Policy AttachmentExhibit1702A960-3, Seclusion and , Restraint, and Emergency Safety Response Monitoring Requirements.
Date / Time (24-hour clock) / Name of Primary Person involved in the Restraint / Credentials/Title of Primary Person involved in the Restraint
Start / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
End / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.

Face-to-Face Assessment

The member must receive a face-to-face assessment of physical and psychological well-being from the Psychiatrist, Registered Nurse (with one year of behavioral health experience) within one (1) hour of initiation of the restraint or seclusion.
Name/Credentials/Title of Primary Person involved in the Restraint: Click here to enter text.

Date of Assessment: Click here to enter text.

Time (24-hour clock) of Assessment: Click here to enter text.

Additional monitoring and face-to-face assessment sections as well as an extended monitoring chart are located at the end of this form.

Clinical Justification to Continue Restraint or Seclusion

☐ Continues at risk for danger to self/Unable to agree to safety alliance
☐ Continues at risk for danger to others/Unable to agree to safety alliance
☐ No improvement of mental status
☐ Unable to follow verbal commands
☐ Medication administration not completed

Click here to enter text.Able to follow verbal commands

Clinical Justification to Discontinue Restraint or Seclusion

☐ No risk for danger to self/Agrees to safety alliance
☐ No risk for danger to others/Agrees to safety alliance
☐ Improvement of mental status
 Meets all criteria for release
☐ Medication administration completed
☐ Able to follow verbal commands
☐ Meets all criteria for release

Injuries

Was the member physically injured DURING (not prior to) the restraint and/or seclusion?  Yes  No
If yes, explain the nature of the injury and complete an Incident, Accident, and Death report: /
Explain the level of medical intervention needed: Click here to enter text.
(e.g. first aid, physician, hospitalization, death)

This section MUST be completed if a member was injured during a seclusion/restraint procedure.

Incident, Accident, and Death (If Applicable)

(T/RBHAs The Contractor or TRBHA[5] must ensure timely and accurate reporting of incidents, accidents, and deaths involving members to AHCCCS Clinical Quality Management.the ADHS/DBHS Bureau of Quality and Integration (BQ&I) Office of Quality of Care (QOC). See ADHS/DBHS Policy 1703, “Reporting of Incidents, Accidents, and Deaths” for guidance.)
Date of Incident, Accident, and Death Report completed:
Name/Credentials/Title of All Persons involved in the Seclusion/Restraint procedure:

Follow-Up[6]

Follow-Up

Was the treating provider notified?

/  Yes, Name of provider: / Date of Notification:
 No (If no, explain):

Was the family/guardian notified?

/  Yes, Name and relationship of the person notified: / Date of Notification:
 No (If no, explain):

Were the findings of assessment discussed?

/  Yes, with whom: / Date of Discussion:
 No (If no, explain):

Was the need for other interventions/treatment reviewed?

/  Yes, with whom: / Date of Review:
 No (If no, explain):

Were revisions made to the treatment plan?

/  Yes, Describe revisions: / Date of Revisions:
 No (If no, explain):

Were Seclusion and Restraint orders completed? Check all boxes that apply and attach orders when submitting Seclusion & Restraint form.

/  Initial Order
 Continuation Order
 Discontinuation Order

Were monitoring sheets completed (every 15 minutes or every 5 minutes)? Attach monitoring sheets when submitting Seclusion & Restraint form.

/  Yes, Date(s) of Completion:
 No (If no, explain):

Debriefing

Member Debriefing

Date of Debriefing: Click here to enter a date.

Time (24-hour clock) of Debriefing: Click here to enter text.
Name/Credentials/Title of Primary Person involved in the Debriefing: Click here to enter text.

Other participants involved in the debriefing: Click here to enter text.

Information discussed during the debriefing: Click here to enter text.

Staff Debriefing

Date of Debriefing: Click here to enter a date.

Time (24-hour clock) of Debriefing: Click here to enter text.
Name/Credentials/Title of all staff in attendance in the Debriefing: Click here to enter text.
Identified intervention opportunities that may have prevented the incident: Click here to enter text.
Things that were done well and/or team strengths: Click here to enter text.
Ways the team could strengthen their response to future incidents: Click here to enter text.
Information discussed during the debriefing: Click here to enter text.
Procedures that can be implemented to prevent recurrence: Click here to enter text.
Systemic changes: Click here to enter text.
Alternatives for this member: Click here to enter text.
Outcome of Debriefing (including actions taken to avoid future use of seclusion or restraint/ identification or alternatives to seclusion and restraint on an individual and systemic levels): Click here to enter text.
Any recommended changes to the ISP as identified in the debriefing: [7]

Follow-Up

Was the treating provider notified?

/ ☐ Yes, Name of provider: / Date of Notification:
Click here to enter text.
☐ No (If no, explain):

Was the family/guardian notified?

/ ☐ Yes, Name and relationship of the person notified: / Date of Notification:
Click here to enter text.
☐ No (If no, explain):

Were the findings of face to face and nursing assessment discussed?

/ ☐ Yes, with whom: / Date of Discussion:
Click here to enter text.
☐ No (If no, explain):

Was the need for other interventions/treatment reviewed?

/ ☐ Yes, with whom: / Date of Review:
Click here to enter text.
☐ No (If no, explain):

Were revisions made to the treatment plan or scheduled?

/ ☐ Yes, Describe revisions: / Date of Revisions:
☐ No (If no, explain):

Were Seclusion and Restraint orders completed? Check all boxes that apply and attach orders when submitting Seclusion & Restraint form.

/ ☐ Initial Order
☐ Continuation Order
☐ Discontinuation Order

Were monitoring sheets completed (every 15 minutes or every 5 minutes)? Attach monitoring sheets when submitting Seclusion & Restraint form.

/ ☐ Yes, Date(s) of Completion:
☐ No (If no, explain):

Were the findings of the assessment discussed?

/ ☐ Yes, Date(s) of Completion:
☐ No (If no, explain):

Were the findings of the assessment discussed?

Final Sign-Off

Name of Director of Nursing or Designee reviewing Seclusion and Restraint Documentation: Click here to enter text.

Director of Nursing or Designee Phone Number: Click here to enter text.

Date of Sign-off: Click here to enter text.

Time (24-hour clock) of Sign-off: Click here to enter text.

Supplemental Monitoring and Face-to-Face Assessment Sections

Face-to-Face Assessment

Date of Assessment:

Time (24-hour clock) of Assessment:
Monitoring
The member must be checked at a minimum of every 15 minutes to ensure the behavioral health member’s comfort and safety. The member must be checked every 5 minutes if he/she has a medical condition that places him/her at a greater risk, as determined by the facility, by the restraint or seclusion. Attach internal documentation of face-to-face monitoring for all episodes that require such documentation per R9-10-225 or R9-10-226. Addendum content must include requirements contained in ADHS/DBHS Policy Attachment 1702A, Seclusion, Restraint, and Emergency Safety Response Monitoring Requirements.
Date / Time (24-hour clock) / Name of Primary Person involved in the Restraint / Credentials/Title of Primary Person involved in the Restraint
Start
End

Face-to-Face Assessment

Date of Assessment:

Time (24-hour clock) of Assessment:

Supplemental Monitoring Section

Monitoring
The member must be checked at a minimum of every 15 minutes to ensure the behavioral health member’s comfort and safety. The member must be checked every 5 minutes if he/she has a medical condition that places him/her at a greater risk, as determined by the facility, by the restraint or seclusion. Attach internal documentation of face-to-face monitoring for all episodes that require such documentation per R9-10-225 or R9-10-226. Addendum content must include requirements contained in ADHS/DBHS Policy Attachment 1702A, Seclusion, Restraint, and Emergency Safety Response Monitoring Requirements.The member must be checked at a minimum of every 15 minutes to ensure the behavioral health member’s comfort and safety. The member must be checked every 5 minutes if he/she has a medical condition that places him/her at a greater risk, as determined by the facility, by the restraint or seclusion. Attach internal documentation of face-to-face monitoring for all episodes that require such documentationperR9-10-225orR9-10-226. Addendum content must include requirements contained in ADHS/DBHS Policy Attachment 1702A, Seclusion, Restraint, and Emergency Safety Response Monitoring Requirements.
Date / Time (24-hour clock) / Name of Primary Person involved in the Restraint / Credentials/Title of Primary Person involved in the Restraint
Start
End

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/Effective Date: 7/01/20161Effective: 02/01/2016

[1] Emergency Safety Response is not required from Level 1 Behavioral Health BHIF. This applies to BHRF and is monitored separately through licensing and audits.

[2] Arizona Laws 2015, Chapter 19, Section 9 (SB 1480) enacts that from and after June 30, 2016, the provision of behavioral health services under DBHS in the Department of Health Services is transferred to and shall be administered by the AHCCCS.

[3] Reason for deletion?

[4] Clarification, current practice.

[5] POST APC CHANGE: align language

[6] Moved to the end of this document, conformity.

[7] Not required